Frailty in relation to the risk of falls, fractures, and mortality in older Chinese adults: results from the Beijing Longitudinal Study of Aging

Systematic review of methods used in prediction models with recurrent event data

BACKGROUND

Patients who suffer from chronic conditions or diseases are susceptible to experiencing repeated events of the same type (e.g. seizures), termed 'recurrent events'. Prediction models can be used to predict the risk of recurrence so that intervention or management can be tailored accordingly, but statistical methodology can vary. The objective of this systematic review was to identify and describe statistical approaches that have been applied for the development and validation of multivariable prediction models with recurrent event data. A secondary objective was to informally assess the characteristics and quality of analysis approaches used in the development and validation of prediction models of recurrent event data.

METHODS

Searches were run in MEDLINE using a search strategy in 2019 which included index terms and phrases related to recurrent events and prediction models. For studies to be included in the review they must have developed or validated a multivariable clinical prediction model for recurrent event outcome data, specifically modelling the recurrent events and the timing between them. The statistical analysis methods used to analyse the recurrent event data in the clinical prediction model were extracted to answer the primary aim of the systematic review. In addition, items such as the event rate as well as any discrimination and calibration statistics that were used to assess the model performance were extracted for the secondary aim of the review.

RESULTS

A total of 855 publications were identified using the developed search strategy and 301 of these are included in our systematic review. The Andersen-Gill method was identified as the most commonly applied method in the analysis of recurrent events, which was used in 152 (50.5%) studies. This was closely followed by frailty models which were used in 116 (38.5%) included studies. Of the 301 included studies, only 75 (24.9%) internally validated their model(s) and three (1.0%) validated their model(s) in an external dataset.

CONCLUSIONS

This review identified a variety of methods which are used in practice when developing or validating prediction models for recurrent events. The variability of the approaches identified is cause for concern as it indicates possible immaturity in the field and highlights the need for more methodological research to bring greater consistency in approach of recurrent event analysis. Further work is required to ensure publications report all required information and use robust statistical methods for model development and validation.

PROSPERO REGISTRATION

CRD42019116031.

Association between disability and cognitive function in older Chinese people: a moderated mediation of social relationships and depressive symptoms

Objective

Many previous studies have found that disability leads to cognitive impairment, and in order to better understand the underlying mechanisms between disability and cognitive impairment, the present study aimed to investigate the moderating role of social relationships, including their role as mediators between disability and cognitive impairment in depressive symptoms.

Study design

This is a cross-sectional study.

Methods

A total of 5,699 Chinese older adults from the 2018 China Longitudinal Healthy Longevity Survey (CLHLS) were included in this study, and PROCESS macro was used to perform simple mediator and moderator mediator analyses, which were used to analyze the relationship between depressive symptoms and social relationships between disability and cognitive impairment.

Results

The results of this study showed significant correlations between disability, cognitive impairment, depressive symptoms, and social relationships, and that depressive symptoms mediated the relationship between disability and cognitive functioning [B = -0.232; 95% CI: (-0.304, -0.164)], and that social relationships mediated disability and cognitive functioning through pathway a (Disability-Depressive Symptoms) [B = 0.190; 95% CI: (0.020, 0.036)], path b (depressive symptoms-cognitive impairment) [B = 0.029; 95% CI: (0.015, 0.042)], and path c' (incapacitation-cognitive impairment) [B = 0.492; 95% CI: (0.298, 0.685)] to modulate the effect of incapacitation on cognitive impairment. In addition, social activities and social networks moderated the mediation model directly or indirectly, whereas social support moderated only the direct effect.

Conclusion

This study explains the intrinsic link between incapacitation and cognitive impairment in Chinese older adults, and that social relationships and depressive symptoms can directly or indirectly modulate the effects between them. This provides a basis for healthcare professionals to be able to better develop interventions that can be used to improve the level of cognitive functioning and mental health of older adults.

Incorporating frailty to address the key challenges to geriatric economic evaluation

BACKGROUND

The multidimensional and dynamically complex process of ageing presents key challenges to economic evaluation of geriatric interventions, including: (1) accounting for indirect, long-term effects of a geriatric shock such as a fall; (2) incorporating a wide range of societal, non-health outcomes such as informal caregiver burden; and (3) accounting for heterogeneity within the demographic group. Measures of frailty aim to capture the multidimensional and syndromic nature of geriatric health. Using a case study of community-based falls prevention, this article explores how incorporating a multivariate frailty index in a decision model can help address the above key challenges.

METHODS

A conceptual structure of the relationship between geriatric shocks and frailty was developed. This included three key associations involving frailty: (A) the shock-frailty feedback loop; (B) the secondary effects of shock via frailty; and (C) association between frailty and intervention access. A case study of economic modelling of community-based falls prevention for older persons aged 60 + was used to show how parameterising these associations contributed to addressing the above three challenges. The English Longitudinal Study of Ageing (ELSA) was the main data source for parameterisation. A new 52-item multivariate frailty index was generated from ELSA. The main statistical methods were multivariate logistic and linear regressions. Estimated regression coefficients were inputted into a discrete individual simulation with annual cycles to calculate the continuous variable value or probability of binary event given individuals' characteristics.

RESULTS

All three conceptual associations, in their parameterised forms, contributed to addressing challenge (1). Specifically, by worsening the frailty progression, falls incidence in the model increased the risk of falling in subsequent cycles and indirectly impacted the trajectories and levels of EQ-5D-3 L, mortality risk, and comorbidity care costs. Intervention access was positively associated with frailty such that the greater access to falls prevention by frailer individuals dampened the falls-frailty feedback loop. Association (B) concerning the secondary effects of falls via frailty was central to addressing challenge (2). Using this association, the model was able to estimate how falls prevention generated via its impact on frailty paid and unpaid productivity gains, out-of-pocket care expenditure reduction, and informal caregiving cost reduction. For challenge (3), frailty captured the variations within demographic groups of key model outcomes including EQ-5D-3 L, QALY, and all-cause care costs. Frailty itself was shown to have a social gradient such that it mediated socially inequitable distributions of frailty-associated outcomes.

CONCLUSION

The frailty-based conceptual structure and parameterisation methods significantly improved upon the methods previously employed by falls prevention models to address the key challenges for geriatric economic evaluation. The conceptual structure is applicable to other geriatric and non-geriatric intervention areas and should inform the data selection and statistical methods to parameterise structurally valid economic models of geriatric interventions.

The Five Times Sit-to-Stand Test is associated with both history of falls and fear of falling among community adults aged 50 years and older

BACKGROUND

Limited evidence has examined the association between balance and mobility measures with risk of fall.

AIM

To determine the prevalence and balance measures associated with falls and fear of falling among community adults aged 50 years and older.

METHODS

This cross-sectional study included community-dwelling adults aged ≥ 50 years, living in Saudi Arabia. The participants were asked to report any history of falls in the past 12 months and fear of falling using the Falls Efficacy Scale (FES-I). Balance/mobility measures included the Timed Up and Go (TUG) test, Functional Reach Test (FRT), 10-m walk test (10-MWT), 6-min walk test (6-MWT), and Five Times Sit-to-Stand Test (5XSST).

RESULTS

Two hundred and six participants, including 96 women, were included. The prevalence of falls was 12.6%, and the 5XSST was the only balance measure significantly associated with falls (OR 1.17, 95% CI [1.03, 1.33], p = 0.019) with a cutoff score of 13.93 s or more, a sensitivity of 0.73, and a specificity of 0.58. An increase in 5XSST time was associated with an increase in FES-I score, while a decrease in other balance measures (10-MWT, TUG, FRT, and 6-MWT) was associated with an increase in FES-I scores.

CONCLUSION

Adults living in Saudi Arabia had a low prevalence of falls. The 5XSST was the only significant balance/mobility measure that distinguished fallers from non-fallers.

Determining factors that maintain physical function or increase frailty using the Kihon checklist among community-dwelling older adults: a six-year longitudinal study in Agano, Japan

BACKGROUND

A significant increase in the older adult population in Japan will significantly increase healthcare costs. This study aimed to examine the risk factors contributing to robustness transitioning to frailty in older residents.

METHODS

Participants were aged 70 in 2016 and 76 in 2022. Participants were evaluated using the Kihon Checklist (KCL).

RESULTS

Participants for this longitudinal study included 444 older persons who completed the KCL surveys in 2016 and 2022. The follow-up rate was 80.6%; therefore, 358 participants were included in the analysis. The median KCL score increased significantly from 2 to 2016 to 3 in 2022 (p < 0.001). The prevalence of robustness significantly decreased from 60.9 to 48.6% (p = 0.042). In a stepwise logistic regression analysis, robustness was independently associated with regular continuous walks for 15 min and a body mass index of above 18.5%. The following variables were associated with the transition to prefrailty: experiencing a fall in the past year and not going out at least once a week. For the transition to frailty, the variables were turned to family or friends for advice, experienced a fall in the past year, and felt helpless in the last two weeks. The independent factor for the transition from prefrailty to frailty was having a BMI of less than 18.5. In contrast, the independent factor for improving from frailty to robustness or prefrailty was going out at least once a week.

CONCLUSIONS

We recommend maintaining continuous walking for more than 15 min, maintaining a BMI of at least 18.5, and going out more than once a week to improve being house-bounded and depressive mood, not only to prevent the transition to prefrailty or frailty but also to improve frailty.

Multisystem physiological perspective of human frailty and its modulation by physical activity

"Frailty" is a term used to refer to a state characterized by enhanced vulnerability to, and impaired recovery from, stressors compared with a nonfrail state, which is increasingly viewed as a loss of resilience. With increasing life expectancy and the associated rise in years spent with physical frailty, there is a need to understand the clinical and physiological features of frailty and the factors driving it. We describe the clinical definitions of age-related frailty and their limitations in allowing us to understand the pathogenesis of this prevalent condition. Given that age-related frailty manifests in the form of functional declines such as poor balance, falls, and immobility, as an alternative we view frailty from a physiological viewpoint and describe what is known of the organ-based components of frailty, including adiposity, the brain, and neuromuscular, skeletal muscle, immune, and cardiovascular systems, as individual systems and as components in multisystem dysregulation. By doing so we aim to highlight current understanding of the physiological phenotype of frailty and reveal key knowledge gaps and potential mechanistic drivers of the trajectory to frailty. We also review the studies in humans that have intervened with exercise to reduce frailty. We conclude that more longitudinal and interventional clinical studies are required in older adults. Such observational studies should interrogate the progression from a nonfrail to a frail state, assessing individual elements of frailty to produce a deep physiological phenotype of the syndrome. The findings will identify mechanistic drivers of frailty and allow targeted interventions to diminish frailty progression.

Economic model of community-based falls prevention: seeking methodological solutions in evaluating the efficiency and equity of UK guideline recommendations

Background

Falls significantly harm geriatric health and impose substantial costs on care systems and wider society. Decision modelling can inform the commissioning of falls prevention but face methodological challenges, including: (1) capturing non-health outcomes and societal intervention costs; (2) considering heterogeneity and dynamic complexity; (3) considering theories of human behaviour and implementation; and (4) considering issues of equity. This study seeks methodological solutions in developing a credible economic model of community-based falls prevention for older persons (aged 60 +) to inform local falls prevention commissioning as recommended by UK guidelines.

Methods

A framework for conceptualising public health economic models was followed. Conceptualisation was conducted in Sheffield as a representative local health economy. Model parameterisation used publicly available data including English Longitudinal Study of Ageing and UK-based falls prevention trials. Key methodological developments in operationalising a discrete individual simulation model included: (1) incorporating societal outcomes including productivity, informal caregiving cost, and private care expenditure; (2) parameterising dynamic falls-frailty feedback loop whereby falls influence long-term outcomes via frailty progression; (3) incorporating three parallel prevention pathways with unique eligibility and implementation conditions; and (4) assessing equity impacts through distributional cost-effectiveness analysis (DCEA) and individual-level lifetime outcomes (e.g., number reaching ‘fair innings’). Guideline-recommended strategy (RC) was compared against usual care (UC). Probabilistic sensitivity, subgroup, and scenario analyses were conducted.

Results

RC had 93.4% probability of being cost-effective versus UC at cost-effectiveness threshold of £20,000 per QALY gained under 40-year societal cost-utility analysis. It increased productivity and reduced private expenditure and informal caregiving cost, but productivity gain and private expenditure reduction were outstripped by increases in intervention time opportunity costs and co-payments, respectively. RC reduced inequality delineated by socioeconomic status quartile. Gains in individual-level lifetime outcomes were small. Younger geriatric age groups can cross-subsidise their older peers for whom RC is cost-ineffective. Removing the falls-frailty feedback made RC no longer efficient or equitable versus UC.

Conclusion

Methodological advances addressed several key challenges associated with falls prevention modelling. RC appears cost-effective and equitable versus UC. However, further analyses should confirm whether RC is optimal versus other potential strategies and investigate feasibility issues including capacity implications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-023-03916-z.

Progression of frailty as measured by a cumulative deficit index: A systematic review

BACKGROUND

Frailty is a risk factor for adverse health outcomes. There is a paucity of literature on frailty progression defined by a cumulative deficit model among community dwelling older people. The objective of this review was to synthesise evidence on these changes in health and mortality among community-dwelling older people.

METHODS

Six databases (Medline, Embase, CINAHL, Cochrane, PsycInfo, Web of Science) and a clinical trials registry were searched in July 2021. The inclusion criteria were studies using a frailty index and providing information on transition between frailty states or to death in community-dwelling older people aged ≥ 50. Exclusion criteria were studies examining specific health conditions, conference abstracts and non-English studies. To standardise the follow-up period and facilitate comparison, we converted the transition probabilities to annual transition rates.

RESULTS

Two reviewers independently screened 5078 studies and 61 studies were included for analysis. Of these, only three used the same frailty state cut-points to facilitate cross-cohort comparison. This review found that frailty tends to increase with time, people who are frail at baseline have greater likelihood to progress in frailty and die, and the main factor that accelerates frailty progression is age. Other risk factors for progression are having chronic disease, smoking, obesity, low-income or/and low-education levels. A frailty index is an accurate predictor of adverse outcomes and death.

DISCUSSION

This systematic review demonstrated that worsening in frailty was a common frailty transition, and older people who are frail at baseline are more likely to die. A frailty index has significant power to predict adverse health outcomes. It is a useful tool for within-cohort comparison but there are challenges comparing different cohorts due to dependence of frailty progression on age and differences in how frailty index is defined and measured.

Frailty Index as a Predictor of Mortality in Middle-Aged and Older People: A Prospective Analysis of Chilean Adults

We aimed to investigate the association between frailty status and all-cause mortality in middle-aged and older people. We included 2661 individuals aged ≥ 35 from the Chilean National Health Survey 2009−2010. Mortality was determined through linkage with the Chilean Civil Registry and Identification. A 36-item frailty index (FI) was used to assess the frailty status. Associations between frailty status and all-cause mortality were assessed using Kaplan−Meier and Cox proportional hazard models adjusted for sociodemographic and lifestyle factors. A non-linear association was investigated using penalized cubic splines fitted in the Cox models. During an 8.9 median follow-up (interquartile range of 8.6−9.0), 308 individuals died (11.5%). Lower survival rates were observed in frail individuals compared to pre-frail and robust people (log-rank < 0.001). Compared with robust individuals, frail people had a higher mortality risk (HR: 2.35 [95% CI: 1.57 to 3.51]). Frail middle-aged individuals had a higher risk of dying independently of major risk factors.

Associations between Frailty and Ambient Temperature in Winter: Findings from a Population-Based Study

Frailty is an accumulation of deficits characterized by reduced resistance to stressors and increased vulnerability to adverse outcomes. However, there is little known about the effect of ambient temperature in winter on frailty among older adults, a population segment with the highest frailty prevalence. Thus, the objective of this study is to investigate the associations between frailty and ambient temperature in winter among older adults. This study was based on the Chinese Longitudinal Healthy Longevity Survey (CLHLS) of older adults aged ≥65 years from the 2005, 2008, 2011, and 2014 waves. The 39-item accumulation of frailty index (FI) was used to assess the frailty status of the participants. The FI was categorized into three groups as follows: robust (FI ≤ 0.10), prefrail (FI > 0.10 to <0.25), and frail (FI ≥ 0.25). Generalized linear mixed models (GLMMs) were conducted to explore the associations between frailty and ambient temperature in winter. A generalized estimating equation (GEE) modification was applied in the sensitivity analysis. A total of 9421 participants were included with a mean age of 82.81 (SD: 11.32) years. Compared with respondents living in the highest quartile (≥7.5 °C) of average temperature in January, those in the lowest quartile (<−1.9 °C) had higher odds of prefrailty (OR = 1.35, 95% CI 1.17−1.57) and frailty (OR = 1.61, 95%CI 1.32−1.95). The associations were stronger among the low-education groups, agricultural workers before retirement, and non-current exercisers. Additionally, results from the GEE model reported consistent findings. Lower levels of ambient temperature in winter were associated with higher likelihoods of prefrailty and frailty. The findings on vulnerability characteristics could help improve public health practices to tailor cold temperature health education and warning information.

Association Among Cognition, Frailty, and Falls and Self-Reported Incident Fractures: Results From the Canadian Longitudinal Study on Aging (CLSA)

Cognition, frailty, and falls have been examined independently as potential correlates of fracture risk, but not simultaneously. Our objective was to explore the association between cognition, frailty, and falls and self-reported incident fractures to determine if these factors show significant independent associations or interactions. We included participants who completed the Canadian Longitudinal Study on Aging (CLSA) 2012-2015 baseline comprehensive assessment, did not experience any self-reported fractures in the year prior to cohort recruitment, and completed the follow-up questionnaire at year 3 (n = 26,982). We compared all baseline cognitive measures available in the CLSA, the Rockwood Frailty Index (FI), and presence of self-reported falls in the past 12 months in those with versus without self-reported incident fractures in year 3 of follow-up. We used multivariable logistic regression adjusted for covariates and examined two-way interactions between cognition, frailty, and prior falls. CLSA specified analytic weights were applied. The mean ± standard error (SE) age of participants was 59.5 ± 0.1 years and 52.2% were female. A total of 715 participants (2.7%) self-reported incident fractures at 3-year follow-up. Participants who experienced incident fractures had similar baseline cognition scores (mean ± SE; Rey Auditory Verbal Learning Test [RAVLT]: Immediate recall 6.1 ± 0.1 versus 5.9 ± 0.0; standardized difference [d] 0.124); higher FI scores (mean ± SE; FI 0.134 ± 0.005 versus 0.116 ± 0.001; d 0.193), and a greater percentage had fallen in the past 12 months (weighted n [%] 518 [7.2] versus 919 [3.5]; d 0.165). FI (each increment of 0.08) was associated with a significantly increased risk of self-reported incident fractures in participants of all ages and those aged 65 years or older (adjusted odd ratio [OR] 1.24, 95% confidence limit [CL] 1.10-1.40; adjusted OR 1.44, 95% CL 1.11-1.52, respectively). The adjusted odds for self-reported incident fractures in participants of all ages was also significantly associated with falls in the past 12 months prior to baseline (adjusted OR 1.83; 95% CL 1.13-2.97), but not in those aged 65 years or older. No interactions between cognition, frailty, and prior falls were found. However, considering the relatively young age of our cohort, it may be appropriate to make strong inferences in individuals older than 65 years of age. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

The impact of household wastewater on the frailty state of the elderly in China: based on a long-term cohort study in China

China's household wastewater discharge has gradually increased, and its composition has become more complex, but the discharge treatment system is not perfect. At present, there is a lack of research on the impact of domestic wastewater on human health, especially on the frailty of the elderly. This study aimed to quantitatively assess the relationship between living wastewater and its main components and the frailty status of the elderly. The research data comes from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), which consists of participants over 60 years old who participated in the three-wave survey in 2008, 2011, and 2014 and combined with domestic wastewater data in the statistical yearbook. A generalized estimating equation (GEE) model was used to assess the link between living wastewater and frailty status in the elderly. The single-pollutant model showed that there was a positive correlation between the discharge of household wastewater and the frailty of the elderly, OR (4.443), 95%CI (3.591, 5.498); ammonia nitrogen had a positive correlation with the frail state of the elderly, OR (4.527), 95%CI (3.587, 5.714); chemical oxygen demand (COD) had a negative association with whether the elderly are frail, OR (0.776), 95%CI (0.609, 0.988). After adjusting for covariates, there was still a positive correlation between household wastewater and the frailty of the elderly, OR (2.792), 95%CI (2.233, 3.492); a positive correlation between ammonia nitrogen and the frail state of the elderly, OR (2.894), 95%CI (2.284, 3.666). The association between COD and the frail state of the elderly, OR (0.823), 95%CI (0.640, 1.058), showed no correlation between the two. The results show that household wastewater may affect the health of the elderly, promote the occurrence of a frail state of the elderly, and increase the medical burden.

Effect of Body Mass Index on Femur Fracture Location: A Retrospective Database Study

OBJECTIVES

Use a large database design and multivariable analyses to assess the associations between body mass index (BMI) and femur fracture patterns after controlling for other risk factors.

DESIGN

Retrospective cohort study.

SETTING

National insurance claims database of patient records from 2010 to 2018.

PATIENTS/PARTICIPANTS

Patients with femur fracture diagnoses were identified. Patients with multiple fractures within 1 week (polytrauma patients), patients without a BMI diagnosis code within 6 months of fracture, and patients with multiple BMI diagnosis codes (implying a substantial change in weight) were excluded.

INTERVENTION

N/A.

MAIN OUTCOME MEASUREMENTS

Patients were divided into groups based on fracture location: proximal (OTA/AO 31), shaft (OTA/AO 32), or distal (OTA/AO 33). The distribution of femur fractures was compared across BMI categories.

RESULTS

A total of 57,042 patients with femur fracture were identified: 45,586 proximal fractures, 4216 shaft fractures, and 7240 distal fractures. Patients with BMI &lt;29.9 have increased odds ( P &lt; 0.0001) of proximal fracture and decreased odds ( P &lt; 0.0001) of shaft or distal fractures. Patients with BMI &gt;30.0 have decreased odds ( P &lt; 0.0001) of proximal fracture and increased odds ( P &lt; 0.0001) of distal fractures.

CONCLUSIONS

Increasing BMI is associated with a decreased proportion of proximal femur fractures and a corresponding increase in the proportion of shaft and distal fractures. Regression analyses determined that age, sex, osteoporosis, diabetes, and tobacco use are not the cause of this trend.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Developing and validating a scoring system for measuring frailty in patients with hip fracture: a novel model for predicting short-term postoperative mortality

Objectives

Frailty is common among patients with hip fracture and may, in part, contribute to the increased risk of mortality and morbidity after hip fracture surgery. This study aimed to develop a novel frailty score for patients with traumatic hip fracture that could be used to predict postoperative mortality as well as facilitate further research into the role of frailty in patients with hip fracture.

Methods

The Orthopedic Hip Frailty Score (OFS) was developed using a national dataset, retrieved from the Swedish National Quality Registry for Hip Fractures, that contained all adult patients who underwent surgery for a traumatic hip fracture in Sweden between January 1, 2008 and December 31, 2017. Candidate variables were selected from the Nottingham Hip Fracture Score, Sernbo Score, Charlson Comorbidity Index, 5-factor modified Frailty Index, as well as the Revised Cardiac Risk Index and ranked based on their permutation importance, with the top 5 variables being selected for the score. The OFS was then validated on a local dataset that only included patients from Orebro County, Sweden.

Results

The national dataset consisted of 126,065 patients. 2365 patients were present in the local dataset. The most important variables for predicting 30-day mortality were congestive heart failure, institutionalization, non-independent functional status, an age ≥85, and a history of malignancy. In the local dataset, the OFS achieved an area under the receiver-operating characteristic curve (95% CI) of 0.77 (0.74 to 0.80) and 0.76 (0.74 to 0.78) when predicting 30-day and 90-day postoperative mortality, respectively.

Conclusions

The OFS is a significant predictor of short-term postoperative mortality in patients with hip fracture that outperforms, or performs on par with, all other investigated indices.

Level of evidence

Level III, Prognostic and Epidemiological.

A frailty index based on routine laboratory data predicts increased risk of mortality in Chinese community-dwelling adults aged over 55 years: a five-year prospective study

Background

Frailty can be operationalized based on the accumulation of deficits using a frailty index (FI) and is associated with an increased risk of adverse health outcomes. Here, we aim to compare validity of a FI from laboratory data with that of the common clinical FI for prediction of mortality in adults aged 55 + years, also examine whether combined FI could improve identification of adults aged 55 + years at increased risk of death.

Methods

Data for this analysis were obtained from the Beijing Longitudinal Study of Aging that involved 1,257 community-dwelling Chinese people, aged 55 + years at baseline. The main outcome measure was 5-year mortality. An FI-self-report based on 30 self-reported health-related data was constructed. An FI-lab was developed using laboratory data, in addition to pulse, systolic and diastolic blood pressure, pulse pressure, body mass index (BMI) and waist. A combined FI comprised all items from each FI. Kaplan–Meier survival curve and Cox proportional hazards models were performed to evaluate the risk of each FI on death. The area under receiver operating characteristic(ROC) curves were used to compare the discriminative performance of each FI.

Results

Of 1257 participants, 155 died and 156 lost at the end of the 5-year follow-up. The mean FI-self-report score was 0.11 ± 0.10, the FI-lab score was 0.33 ± 0.14 and FI-combined score was 0.19 ± 0.09. Higher frailty level defined by each FI was associated with higher risk of death. After adjustment for age and sex, Cox proportional hazards models showed that the higher scores of frailty were associated with a higher risk of mortality for each FI, the hazard ratios for the FI-self-report and FI-lab and FI-combined were 1.04 (1.03 to 1.05) and 1.02 (1.01 to 1.03) and 1.05 (1.04 to 1.07), respectively. The areas under the ROC curve were 0.79 (0.77–0.82) for the FI-self-report, 0.77(0.75–0.80) for the FI-lab and 0.81(0.78–0.82) for FI-combined.

Conclusions

A FI from laboratory data can stratify older adults at increased risk of death alone and in combination with FI based on self-report data. Assessment in clinical settings of creating an FI using routine collected laboratory data needs to be further developed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03374-z.

M, Srivastava S. Cross-sectional associations of physical frailty with fall, multiple falls and fall-injury among older Indian adults: Findings from LASI, 2018

BACKGROUND

Although there has been a range of studies that focused on physical frailty and associated fall outcomes within developed countries, similar studies from developing countries have been limited. This study aimed to examine the relationship between physical frailty and the prevalence of falls, multiple falls and fall-related injuries among the ageing population within the Indian context.

METHODS

Individual-level data from the first wave of the Longitudinal Aging Study in India (LASI) with 28,285 older adults aged 60 years and above (male 48.9%) was used for this study. Physical frailty was assessed through the physical frailty phenotype adapted from Fried's criteria. Multivariable logistic regression was employed to examine the association of frailty status with falls, multiple falls, and fall-related injuries among Indian older adults.

RESULTS

The prevalence of frailty was found to be 29.94% within the sample and frail older adults had a higher prevalence of falls (15.43% vs 11.85%), multiple falls (7.73% vs 5.25%), and fall related injuries (6.68% vs 5.29%). The odds of falling among frail older adults were significantly higher in reference to the odds of falling among non-frail older adults [aOR: 1.24; CI: 1.09-1.41]. Similarly, the odds of multiple falls among frail older adults were significantly higher in reference to the odds of multiple falls among non-frail older adults [aOR: 1.24; CI: 1.05-1.48]. Moreover, the odds of fall-related injury among frail older adults were significantly higher in reference to the odds of fall-related injury among non-frail older adults [aOR: 1.21; CI: 1.01-1.45]. Falls, multiple falls and fall-related injuries were found to be significantly associated with employment and poor self-rated health, whereas, females and lone living older adults had a significantly higher likelihood of suffering from falls and multiple falls.

CONCLUSION

Older individuals with physical frailty were found to be at increased risk of falls, multiple falls and fall-related injuries in India. The findings of our study also have important clinical implications in the measures undertaken to reduce falls and enable future healthcare practitioners and policymakers to factor in the key determinant of physical frailty.

Systematic review and critical methodological appraisal of community-based falls prevention economic models

BACKGROUND

Falls impose significant health and economic burdens on community-dwelling older persons. Decision modelling can inform commissioning of alternative falls prevention strategies. Several methodological challenges arise when modelling public health interventions including community-based falls prevention. This study aims to conduct a systematic review (SR) to: systematically identify community-based falls prevention economic models; synthesise and critically appraise how the models handled key methodological challenges associated with public health modelling; and suggest areas for further methodological research.

METHODS

The SR followed the 2021 PRISMA reporting guideline and covered the period 2003-2020 and 12 academic databases and grey literature. The extracted methodological features of included models were synthesised by their relevance to the following challenges: (1) capturing non-health outcomes and societal intervention costs; (2) considering heterogeneity and dynamic complexity; (3) considering theories of human behaviour and implementation; and (4) considering equity issues. The critical appraisal assessed the prevalence of each feature across models, then appraised the methods used to incorporate the feature. The methodological strengths and limitations stated by the modellers were used as indicators of desirable modelling practice and scope for improvement, respectively. The methods were also compared against those suggested in the broader empirical and methodological literature. Areas of further methodological research were suggested based on appraisal results.

RESULTS

46 models were identified. Comprehensive incorporation of non-health outcomes and societal intervention costs was infrequent. The assessments of heterogeneity and dynamic complexity were limited; subgroup delineation was confined primarily to demographics and binary disease/physical status. Few models incorporated heterogeneity in intervention implementation level, efficacy and cost. Few dynamic variables other than age and falls history were incorporated to characterise the trajectories of falls risk and general health/frailty. Intervention sustainability was frequently based on assumptions; few models estimated the economic/health returns from improved implementation. Seven models incorporated ethnicity- and severity-based subgroups but did not estimate the equity-efficiency trade-offs. Sixteen methodological research suggestions were made.

CONCLUSION

Existing community-based falls prevention models contain methodological limitations spanning four challenge areas relevant for public health modelling. There is scope for further methodological research to inform the development of falls prevention and other public health models.

Dementia is a surrogate for frailty in hip fracture mortality prediction

Purpose

Among hip fracture patients both dementia and frailty are particularly prevalent. The aim of the current study was to determine if dementia functions as a surrogate for frailty, or if it confers additional information as a comorbidity when predicting postoperative mortality after a hip fracture.

Methods

All adult patients who suffered a traumatic hip fracture in Sweden between January 1, 2008 and December 31, 2017 were considered for inclusion. Pathological fractures, non-operatively treated fractures, reoperations, and patients missing data were excluded. Logistic regression (LR) models were fitted, one including and one excluding measurements of frailty, with postoperative mortality as the response variable. The primary outcome of interest was 30-day postoperative mortality. The relative importance for all variables was determined using the permutation importance. New LR models were constructed using the top ten most important variables. The area under the receiver-operating characteristic curve (AUC) was used to compare the predictive ability of these models.

Results

121,305 patients were included in the study. Initially, dementia was among the top ten most important variables for predicting 30-day mortality. When measurements of frailty were included, dementia was replaced in relative importance by the ability to walk alone outdoors and institutionalization. There was no significant difference in the predictive ability of the models fitted using the top ten most important variables when comparing those that included [AUC for 30-day mortality (95% CI): 0.82 (0.81–0.82)] and excluded [AUC for 30-day mortality (95% CI): 0.81 (0.80–0.81)] measurements of frailty.

Conclusion

Dementia functions as a surrogate for frailty when predicting mortality up to one year after hip fracture surgery. The presence of dementia in a patient without frailty does not appreciably contribute to the prediction of postoperative mortality.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01960-9.

The mortality trends of falls among the elderly adults in the mainland of China, 2013-2020: A population-based study through the National Disease Surveillance Points system

BACKGROUND

Fall in elderly is a major public health problem. Characterizing trends in fall mortality in different subpopulations could help identifying the needs and developing preventive program for target groups. Here we evaluated the trends of fall-related deaths in Chinese mainland among adults aged ≥60 years specific in sex, age, and provinces, to measure the change in this mortality rate between 2013 and 2020, and to explore the underlying factors influencing this change.

METHODS

Mortality data were retrieved from the National Disease Surveillance Points system(DSPs) of China, a national-level and provincial-level representative data source, to estimate the impact of elderly falls on mortality in the mainland of China and the specific provinces from 2013 to 2020. The joinpoint regression model was used to estimate the temporal trend of mortality in elderly fallen by calculating the annual percentage change (APC).

FINDINGS

The age-standardized falls mortality was 10·438 per 100 000 in 2020. The age-standardized mortality of elderly falls in total and female showed a steady increasing trend (APC=1·96%, p = 0·023 total; APC=3·42%, p = 0·003 female), with it was stable in males (APC=1.26%, p>0·05). Fall mortality among the elderly was more common in people over 70 years of age and increased sharply. The death rates and APCs were highest among the oldest age groups(aged≥85 years). The higher fall mortality was mainly focused in the southeast and central regions, and lower rates were in the northeast provinces and Tibet.

INTERPRETATION

Since 2013, the overall fall-related mortality trend among individuals aged ≥60 years has been consistently increasing in China, making it most critical public health challenge. Adherence interventions and increased social support for those at most risk should be considered.

FUNDING

None.

Clinical Practice Guidelines for Managing Frailty in Community-Dwelling Korean Elderly Adults in Primary Care Settings

Aging has become a global problem, and the interest in healthy aging is growing. Healthy aging involves a focus on the maintenance of the function and well-being of elderly adults, rather than a specific disease. Thus, the management of frailty, which is an accumulated decline in function, is important for healthy aging. The adaptation method was used to develop clinical practice guidelines on frailty management that are applicable in primary care settings. The guidelines were developed in three phases: preparation (organization of committees and establishment of the scope of development), literature screening and evaluation (selection of the clinical practice guidelines to be adapted and evaluation of the guidelines using the Korean Appraisal of Guidelines for Research and Evaluation II tool), and confirmation of recommendations (three rounds of Delphi consensus and internal and external reviews). A total of 16 recommendations (five recommendations for diagnosis and assessment, 11 recommendations for intervention of frailty) were made through the guideline development process. These clinical practice guidelines provide overall guidance on the identification, evaluation, intervention, and monitoring of frailty, making them applicable in primary care settings. As aging and “healthy aging” become more and more important, these guidelines are also expected to increase in clinical usefulness.

Frailty Status Among the Elderly of Different Genders and the Death Risk: A Follow-Up Study

Background: Frailty in the elderly population is currently a frontier and focus in the field of health and aging. The goal of this study was to explore the frailty status among the elderly of different genders and its influence on the risk of death during 11 years.

Methods: Frailty index (FI) was used to evaluate the frailty status in the elderly based on the baseline data conducted in 2009; and death as outcome variables collected in 2020 were analyzed. The difference of the frailty level and mortality of different genders was compared. Cox regression and Kaplan–Meier curves were applied to evaluate the influence on the risk of death and the 11-year survival of the elderly at different level of frailty, respectively.

Results: Totally, 1,246 elderly people were recruited. The mortality in men (43.7%, 227/519) was statistically higher than that in women (34.3%, 249/727) (x² = 11.546, P = 0.001). Deficits accumulated exponentially with age, and at all ages, women accumulated more deficits than do men on average (B = 0.030 vs. 0.028, t = 4.137, P = 0.023). For any given level of frailty, the mortality rate is higher in men than in women, and the difference in mortality between genders reached the peak when FI value was 0.26. Cox regression analysis showed that FI value had a greater impact on the risk of death in older men (HR = 1.171, 95%CI: 1.139~1.249)than that in older women (HR = 1.119, 95%CI: 1.039~1.137). Survival analysis showed that the median 11-year survival time in women was longer than that in men (95.26 vs. 89.52 months, Log rank = 9.249, P = 0.002). Kaplan–Meier curves showed that the survival rate decreased with the increase of frailty, and at the same level of frailty, survival time in older women was longer than that in older men, except for severe frailty (FI ≥ 0.5).

Conclusion: The frailty status and its influence on mortality are different among the older people of different genders; therefore, specific interventions for frailty should be conducted in the elderly population of different genders, as well as of different degrees of frailty.

Frailty and length of stay in older adults with blunt injury in a national multicentre prospective cohort study

Background

Patients suffering moderate or severe injury after low falls have higher readmission and long-term mortality rates compared to patients injured by high-velocity mechanisms such as motor vehicle accidents. We hypothesize that this is due to higher pre-injury frailty in low-fall patients, and present baseline patient and frailty demographics of a prospective cohort of moderate and severely injured older patients. Our second hypothesis was that frailty was associated with longer length of stay (LOS) at index admission.

Methods

This is a prospective, nation-wide, multi-center cohort study of Singaporean residents aged ≥55 years admitted for ≥48 hours after blunt injury with an injury severity score or new injury severity score ≥10, or an Organ Injury Scale ≥3, in public hospitals from 2016–2018. Demographics, mechanism of injury and frailty were recorded and analysed by Chi-square, or Kruskal-Wallis as appropriate.

Results

218 participants met criteria and survived the index admission. Low fall patients had the highest proportion of frailty (44, 27.3%), followed by higher level fallers (3, 21.4%) and motor vehicle accidents (1, 2.3%) (p < .01). Injury severity, extreme age, and surgery were independently associated with longer LOS. Frail patients were paradoxically noted to have shorter LOS (p < .05).

Conclusion

Patients sustaining moderate or severe injury after low falls are more likely to be frail compared to patients injured after higher-velocity mechanisms. However, this did not translate into longer adjusted LOS in hospital at index admission.

Association of Frailty Status with Risk of Fall among Middle-Aged and Older Adults in China: A Nationally Representative Cohort Study

OBJECTIVES

To investigate the association between frailty status and risk of fall among middle-aged and older Chinese people.

DESIGN

A nationally representative prospective cohort study.

SETTING AND PARTICIPANTS

The study included 13,877 community-dwelling participants aged 45 years and above from the China Health and Retirement Longitudinal Study.

METHODS

Frailty status was identified by the frailty index of health deficit accumulation. 34 variables at baseline were selected to calculate the frailty index. We excluded participants with incomplete information in construction of the frailty index at baseline. Falls were measured based on the respondents' self-report. We used a logistic regression model to estimate the associations between the frailty status and risk of fall, and subgroup analyses and sensitivity analyses were further conducted.

RESULTS

Of 13,877 participants, 2310 (16.6%) had falls during the observation period. 9027 (65.0%) participants were classified as robust, 4019 (29.0%) participants were classified as pre-frail, and 831 (6.0%) participants were classified as frail. Our results indicated per 0.01 increment in the frailty index was significantly associated with an increased risk of fall among middle-aged and older participants (OR: 1.52, 95%CI: 1.45-1.60). Such association was stronger when frailty was presented as a categorical variable, with an OR of 1.75 (95%CI: 1.59-1.93) for pre-frail and 3.04 (95%CI: 2.60-3.56) for frail. The area under the curve of the logistic model was 0.612 (95%CI: 0.600-0.625). Each 0.01 increment of the frailty index was association with a higher risk of fall among middle-aged (45-59years) participants (OR: 1.44, 95%CI: 1.29-1.60) than among older (≥60 years) participants (OR: 1.28, 95%CI: 1.16-1.41) at baseline (p=0.015 for interaction).

CONCLUSION

Frailty was significantly associated with an increased risk of fall among community-dwelling middle-aged and older people in China. It is necessary to screen and recognize frailty status to prevent falls among middle-aged and older adults.

Comparison of two frailty indexes in hip fractures

AIM

Modified-Krishnan's frailty index (FI) is an FI calculation method developed by Krishnan et al. in 2014. This study aimed to compare the effectiveness and correlation of the FIs from Krishnan and the Canadian study of health and aging (CSHA) in predicting postoperative outcomes of elderly patients with hip fracture.

METHODS

Based on clinical follow-up and observation, we utilized these two instruments to predict 3-month mortality, hip function, and recovery of daily activities. The area under the curve (AUC) and the Pearson correlation coefficient were used to compare the two scales' predictive validities for postoperative outcomes.

RESULTS

A total of 130 patients were included; 67% female and mean age 77.5 ± 8.5 years. The AUCs of modified-Krishnan's FI (AUC = 0.856; 95% confidence interval (CI) = 0.767-0.945) and the CSHA-FI (AUC = 0.793; 95% CI = 0.652-0.934) were used to compare the effectiveness in predicting patient mortality. The optimal predictive scores were 0.335 and 0.28, respectively. The Pearson correlation analysis showed that the modified-Krishnan's FI correlated with the Japanese Orthopaedic Association hip score (pain, activity, walking ability, and ability for daily living; R = -0.249, p = 0.005), while the CSHA-FI was not correlated (R = -0.125, p = 0.170). The modified-Krishnan's FI (R = -0.415, p < 0.001) and the CSHA-FI (R = -0.332, p < 0.001) were both significantly correlated with the functional recovery scale score.

CONCLUSIONS

The modified-Krishnan's FI and the CSHA-FI were effective in the prediction of postoperative mortality. But the modified-Krishnan's FI was more consistently associated with the recovery of hip function and daily activities at 3 months after the operation than that of the CSHA-FI. The modified-Krishnan's FI was more suitable to utilize for risk stratification, identifying deficits, and predicting recovery capacity in hip fracture patients.

Frailty and the risk of all-cause mortality and hospitalization in chronic heart failure: a meta-analysis

To estimate the risk of all-cause mortality and hospitalization in frail patients with chronic heart failure (HF), a systematic search and meta-analysis was carried out to identify all prospective cohort studies conducted among adults with HF where frailty was quantified and related to the primary endpoints of all-cause mortality and/or hospitalization. Twenty-nine studies reporting the link between frailty and all-cause mortality in 18 757 patients were available for the meta-analysis, along with 11 studies, with 13 525 patients, reporting the association between frailty and hospitalization. Frailty was a predictor of all-cause mortality and hospitalization with summary hazard ratios (HRs) of 1.48 [95% confidence interval (CI): 1.31-1.65, P < 0.001] and 1.40 (95% CI: 1.27-1.54, P < 0.001), respectively. Summary HRs for all-cause mortality among frail inpatients undergoing ventricular assist device implantation, inpatients hospitalized for HF, and outpatients were 1.46 (95% CI: 1.18-1.73, P < 0.001), 1.58 (95% CI: 0.94-2.22, P = not significant), and 1.53 (95% CI: 1.28-1.78, P < 0.001), respectively. Summary HRs for all-cause mortality and frailty based on Fried's phenotype were 1.48 (95% CI: 1.03-1.93, P < 0.001) and 1.42 (95% CI: 1.05-1.79, P < 0.001) for inpatients and outpatients, respectively, and based on other frailty measures were 1.42 (95% CI: 1.12-1.72, P < 0.001) and 1.60 (95% CI: 1.43-1.77, P < 0.001) for inpatients and outpatients, respectively. Across clinical contexts, frailty in chronic HF is associated with an average of 48% and 40% increase in the hazard of all-cause mortality and hospitalization, respectively. The relationship between frailty and all-cause mortality is similar across clinical settings and comparing measurement using Fried's phenotype or other measures.

A Comparison of Frailty Assessment Instruments in Different Clinical and Social Care Settings: The Frailtools Project

OBJECTIVE

To determine which of 8 commonly employed frailty assessment tools demonstrate the most appropriate characteristics to be employed in different clinical and social settings.

DESIGN

Cross-sectional multicenter European-based study.

SETTING AND PARTICIPANTS

1440 patients aged ≥75 years evaluated in geriatric inpatient wards, geriatric outpatient clinics, primary care clinics, and nursing homes.

METHODS

The frailty instruments used were Frailty Phenotype, SHARE-FI, 3-item Frailty Trait Scale (FTS-3), 5-item Frailty Trait Scale (FTS-5), FRAIL, 35-item Frailty Index (FI-35), Gérontopôle Frailty Screening Tool (GFST), and Clinical Frailty Scale (CFS). The settings were geriatrics wards, outpatient clinics, primary care, and nursing homes. Suitability was evaluated by considering the feasibility (patients with the test fully completed), administration time (time spent for administering the test), and interscale agreement (Cohen kappa index among instruments to detect frailty).

RESULTS

The prevalence of frailty varied across settings and adopted tests. The scales with the mean highest feasibility were the FRAIL scale (99.4%), SHARE-FI (98.3%), and GFST (95.0%). The mean shortest administration times were obtained with CFS (24 seconds), GFST (72 seconds), and FRAIL scale (90 seconds). The interscale agreement between most of the tests was fair. CFS followed by FTS-5 agreed at least moderately with a greater number of scales overall and in almost all settings.

CONCLUSIONS AND IMPLICATIONS

Based on feasibility, time to undertake the tool, and agreement with other scales, different scales would be recommended according to the setting considered. Our findings suggest that most of the tools evaluated are actually assessing different frailty constructs.

Frailty and prediction of recurrent falls over 10 years in a community cohort of 75-year-old women

Background

Frailty captures the age-related declines in health leading to increased vulnerability, including falls which are commonplace in older women. The relationship between frailty and falls is complex, with one leading to the other in a vicious cycle.

Aims

This study addresses the gap in understanding how patterns of frailty and falls propensity interact, particularly in those who have not yet entered the falls-frailty cycle.

Methods

The Osteoporosis Risk Assessment cohort consists of 1044 community-dwelling women aged 75, with 10 years of follow-up. Investigations were performed and a frailty index constructed at baseline, 5 and 10 years. Falls were self-reported for each previous 12 months. Analysis was two-directional, firstly based on frailty status and second, based on falls status. Recurrent falls was the primary outcome.

Results

Baseline frailty was a significant predictor of recurrent falls after 5 and 10 years [(OR 2.55 (1.62–3.99); 3.04 (1.63–5.67)]. Among women who had no history of falls at age 75, frailty was a stronger predictor of falls at 5 years [OR 3.06 (1.59–5.89)] than among women who had previously fallen.

Discussion

Frailty is significantly associated with recurrent falls and most pronounced in those who are frail but have not yet fallen.

Conclusions

This suggests that frailty should be an integral part of falls-risk assessment to improve identification of those at risk of becoming fallers.

Electronic supplementary material

The online version of this article (10.1007/s40520-019-01467-1) contains supplementary material, which is available to authorized users.

Falls and Fall-Related Consequences among Older People Living in Long-Term Care Facilities in a Megacity of China

INTRODUCTION

Falls are currently the top safety problem in long-term care facilities (LTCFs) in China. Due to the increasing number of residents living in LTCFs, more evidence is needed to give a foundation for fall prevention.

OBJECTIVE

This study aimed to explore the epidemiological characteristics of falls in LTCFs in central Shanghai.

METHODS

The study was conducted in 21 LTCFs in a central district in Shanghai, with a capacity of 3,065 residents. A two-stage sampling method was applied in participant recruitment. Falls were recorded by LTCF staff over a 12-month period. Details of falls were obtained by face-to-face interviews. The χ2 test was used in data analyses.

RESULTS

The incidence of falls was 13.5%; 64.0% falls resulted in injuries, with 32.0% involving fractures. Women had a significantly higher incidence of injurious falls than men (χ2 = 4.066, p = 0.044). Residents aged 80-89 years or in level 1 care had the highest incidence of falls with severe consequences. The incidence of falls was significantly higher at small- or medium-sized LTCFs, public LTCFs, and LTCFs with higher environmental risk levels compared to their counterparts. Most falls occurred when walking on a flat floor (28.9%) and rising up or sitting down (24.0%); 40.9% occurred during the night. Of those injured, 54.8% were treated in hospitals, and only 53.7% completely recovered.

CONCLUSIONS

Though the average incidence of falls in LTCFs in Shanghai was relatively low, great variation was observed between LTCFs, and severe consequences occurred frequently. Fall prevention programmes should be evidence-based with applicable devices and individualized care services and supports. The roles of personal and institutional factors on falls warrant further study.

Frailty as a predictor of future falls and disability: a four-year follow-up study of Chinese older adults

BACKGROUND

Frailty, which is defined as aging-related multisystem impairments, can lead to adverse health outcomes. However, evidence for such a connection in Chinese older adults remains lacking. This study examined the association between frailty and future falls and disability among community-dwelling Chinese older adults.

METHODS

Data were obtained from the 2011 and 2015 waves of the China Health and Retirement Longitudinal Study. Participants were aged 60 years and above at baseline in 2011 and completed the follow-up survey in 2015. Outcome measures were future falls, incident disability in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and worsening performance of ADLs and IADLs. A multivariate logistic regression was conducted to examine the association between frailty phenotype and falls, incident disability, and worsening disability during a four-year period.

RESULTS

We found that frail participants were at increased risk at follow-up for: falls (OR 1.54, 95% CI, 1.14-2.08); developing new ADL difficulties (OR 4.10, 95% CI, 2.79-6.03) and IADL difficulties (OR 3.06, 95% CI, 2.03-4.61); and worsening ADLs performance (OR 2.27, 95% CI, 1.27-4.06), after adjusting for potential confounders. Prefrailty was also significantly associated with future falls, incident disability in ADLs and IADLs, but with a lower magnitude of effect.

CONCLUSIONS

Frailty phenotype is an independent predictor of future falls, incident disability, and worsening performance in ADLs among Chinese older adults. The association suggests the need to pay special attention in caring for frail and prefrail elders and improving individuals' frailty status.

Effects of long-term in vivo micro-CT imaging on hallmarks of osteopenia and frailty in aging mice

In vivo micro-CT has already been used to monitor microstructural changes of bone in mice of different ages and in models of age-related diseases such as osteoporosis. However, as aging is accompanied by frailty and subsequent increased sensitivity to external stimuli such as handling and anesthesia, the extent to which longitudinal imaging can be applied in aging studies remains unclear. Consequently, the potential of monitoring individual mice during the entire aging process-from healthy to frail status-has not yet been exploited. In this study, we assessed the effects of long-term in vivo micro-CT imaging-consisting of 11 imaging sessions over 20 weeks-on hallmarks of aging both on a local (i.e., static and dynamic bone morphometry) and systemic (i.e., frailty index (FI) and body weight) level at various stages of the aging process. Furthermore, using a premature aging model (PolgA(D257A/D257A)), we assessed whether these effects differ between genotypes. The 6th caudal vertebrae of 4 groups of mice (PolgA(D257A/D257A) and PolgA(+/+)) were monitored by in vivo micro-CT every 2 weeks. One group was subjected to 11 scans between weeks 20 and 40 of age, whereas the other groups were subjected to 5 scans between weeks 26-34, 32-40 and 40-46, respectively. The long-term monitoring approach showed small but significant changes in the static bone morphometric parameters compared to the other groups. However, no interaction effect between groups and genotype was found, suggesting that PolgA mutation does not render bone more or less susceptible to long-term micro-CT imaging. The differences between groups observed in the static morphometric parameters were less pronounced in the dynamic morphometric parameters. Moreover, the body weight and FI were not affected by more frequent imaging sessions. Finally, we observed that longitudinal designs including baseline measurements at young adult age are more powerful at detecting effects of in vivo micro-CT imaging on hallmarks of aging than cross-sectional comparisons between multiple groups of aged mice subjected to fewer imaging sessions.

An Artificial Neural Network Model for Assessing Frailty-Associated Factors in the Thai Population

Frailty, one of the major public health problems in the elderly, can result from multiple etiologic factors including biological and physical changes in the body which contribute to the reduction in the function of multiple bodily systems. A diagnosis of frailty can be reached using a variety of frailty assessment tools. In this study, general characteristics and health data were assessed using modified versions of Fried's Frailty Phenotype (mFFP) and the Frail Non-Disabled (FiND) questionnaire (mFiND) to construct a Self-Organizing Map (SOM). Trained data, composed of the component planes of each variable, were visualized using 2-dimentional hexagonal grid maps. The relationship between the variables and the final SOM was then investigated. The SOM model using the modified FiND questionnaire showed a correct classification rate (%CC) of about 66% rather than the model responded to mFFP models. The SOM Discrimination Index (SOMDI) identified cataracts/glaucoma, age, sex, stroke, polypharmacy, gout, and sufficiency of income, in that order, as the top frailty-associated factors. The SOM model, based on the mFiND questionnaire frailty assessment, is an appropriate tool for assessment of frailty in the Thai elderly. Cataracts/glaucoma, stroke, polypharmacy, and gout are all modifiable early prediction factors of frailty in the Thai elderly.

Prediction of Damage Accrual in Systemic Lupus Erythematosus Using the Systemic Lupus International Collaborating Clinics Frailty Index

OBJECTIVE

The Systemic Lupus International Collaborating Clinics (SLICC) frailty index (FI) has been shown to predict mortality, but its association with other important outcomes is unknown. We examined the association of baseline SLICC FI values with damage accrual in the SLICC inception cohort.

METHODS

The baseline visit was defined as the first visit at which both organ damage (SLICC/American College of Rheumatology Damage Index [SDI]) and health-related quality of life (Short Form 36) were assessed. Baseline SLICC FI scores were calculated. Damage accrual was measured by the increase in SDI between the baseline assessment and the last study visit. Multivariable negative binomial regression was used to estimate the association between baseline SLICC FI values and the rate of increase in the SDI during follow-up, adjusting for relevant demographic and clinical characteristics.

RESULTS

The 1,549 systemic lupus erythematosus (SLE) patients eligible for this analysis were mostly female (88.7%) with a mean ± SD age of 35.7 ± 13.3 years and a median disease duration of 1.2 years (interquartile range 0.9-1.5 years) at baseline. The mean ± SD baseline SLICC FI was 0.17 ± 0.08. Over a mean ± SD follow-up of 7.2 ± 3.7 years, 653 patients (42.2%) had an increase in SDI. Higher baseline SLICC FI values (per 0.05 increase) were associated with higher rates of increase in the SDI during follow-up (incidence rate ratio [IRR] 1.19 [95% confidence interval 1.13-1.25]), after adjusting for age, sex, ethnicity/region, education, baseline SLE Disease Activity Index 2000, baseline SDI, and baseline use of glucocorticoids, antimalarials, and immunosuppressive agents.

CONCLUSION

Our findings indicate that the SLICC FI predicts damage accrual in incident SLE, which further supports the SLICC FI as a valid health measure in SLE.

The Clinical Potential of Frailty Indicators on Identifying Recurrent Fallers in the Community: The Mr. Os and Ms. OS Cohort Study in Hong Kong

OBJECTIVES

To compare the clinical value of 3 frailty indicators in a screening pathway for identifying older men and women who are at risk of falls.

DESIGN

A prospective cohort study.

SETTING AND PARTICIPANTS

Four thousand Chinese adults (2000 men) aged ≥65 years were recruited from the community in Hong Kong.

METHODS

The Cardiovascular Health Study Criteria, the FRAIL scale, and the Study for Osteoporosis and Fracture Criteria (SOF) were included for evaluation. Fall history was used as a comparative predictor. Recurrent falls during the second year after baseline was the primary outcome. The area under the receiver operating characteristic curve (AUC) was used to evaluate the ability of the frailty indicators and fall history to predict recurrent falls. Independent predictors identified in logistic regression were put in the Classification and Regression Tree (CART) analysis to evaluate their performance in screening high-risk fallers.

RESULTS

Fall history predicts recurrent falls in both men and women (AUC: men = 0.681; women = 0.645) better than all frailty indicators (AUC ≤ 0.641). After adjusting for fall history, only FRAIL (AUC = 0.676) and SOF (AUC = 0.673) remained as significant predictors for women whereas no frailty indicator remained significant in men. FRAIL could classify older women into 2 groups with distinct chances of being a recurrent faller in people with no fall history (3.8% vs 7.5%), a single fall history (9.5% vs 37.5%), and history of recurrent falls (16.0% vs 30.8%). SOF has limited ability in identifying recurrent fallers in the group of older adults with a single fall history (no fall history: 3.9% vs 8.6%; single fall history: 10.2% vs 10.9%; history of recurrent falls: 16.5% vs 20.6%).

CONCLUSIONS AND IMPLICATIONS

SOF and FRAIL could provide some additional prediction value to fall history in older women but not men. FRAIL could be clinically useful in identifying older women at risk of recurrent falls, especially in those with a single fall history.

Unintentional falls mortality in China, 2006-2016

BACKGROUND

To examine trends in unintentional falls mortality from 2006 to 2016 in China by location (urban/rural), sex, age group and mechanism.

METHODS

Mortality data were retrieved from the National Disease Surveillance Points system (DSPs) of China, a nationally representative data source. Percent change in mortality between 2006 and 2016 was calculated as "mortality rate ratio - 1" based on a negative binomial regression model.

RESULTS

The crude unintentional falls mortality was 9.55 per 100 000 population in 2016. From 2006 to 2016, the age-adjusted unintentional falls mortality increased by 5% (95% confidence interval (CI) = 1%-9%), rising from 7.65 to 8.03 per 100 000 population. Males, rural residents and older age groups consistently had higher falls mortality rates than females, urban residents and younger age groups. Falls on the same level from slipping, tripping and stumbling (W01) was the most common mechanisms of falls mortality, accounting for 29% of total mortality.

CONCLUSIONS

Unintentional falls continued to be a major cause of death in China from 2006 to 2016. Empirically-supported interventions should be implemented to reduce unintentional falls mortality.

Comparison of Two Models of Frailty for the Prediction of Mortality in Brazilian Community-Dwelling Older Adults: The FIBRA Study

BACKGROUND

Prevalence of frailty is significant in Latin America. However, no previous study evaluated mortality prediction using the two most used frailty models in Brazil.

OBJECTIVES

The aim of the present study was to compare the frailty phenotype and the frailty index with regard to accuracy in the prediction of mortality among community-dwelling older adults.

METHODS

A cohort study was conducted involving 674 older adults. Thirty-five variables (signs, symptoms, chronic diseases and disabilities) were used for the construction of the frailty index (FI). The frailty phenotype index (FPI) was defined based on the criteria proposed in the Cardiovascular Health Study. Periodic verifications were performed in the databank of the Mortality Information System. Cox regression was used to estimate the relative risk (RR) of mortality and Kaplan-Meier survival curves were used in the analysis.

RESULTS

The prevalence of frailty was greater based using the FI (16.3%) compared to the FPI (5.34%). Older adults classified as frail by the FPI had a greater risk of death (RR: 10.03; 95% CI: 4.43-22.74) that those classified as frail by the FI (RR: 0.87; 95% CI: 0.25-3.00). The lowest survival rate was found in the group of older adults classified as frail based on the FPI and classified as pre-frail and robust based on the FI.

CONCLUSION

The FPI demonstrated greater accuracy in predicting the risk of mortality among Brazilian older adults than the FI. The validation of frailty measures is fundamental to the identification of older adults who are more vulnerable to adverse health events.

Progression of frailty and prevalence of osteoporosis in a community cohort of older women-a 10-year longitudinal study

In community dwelling, 75-year-old women followed 10 years, a frailty index was created at each of three visits. Frailty score increased by ~ 6-7% annually. A higher frailty score was equivalent to being 5-10 years chronologically older. Frailty was associated with low bone density and higher risk of dying.

INTRODUCTION

To understand the distribution of frailty among a population-based sample of older community-dwelling women, progression over 10 years, and association with mortality and osteoporosis.

METHODS

The study is performed in a cohort designed to investigate osteoporosis. The OPRA cohort consists of 75-year-old women, n = 1044 at baseline, and follow-up at age 80 and 85. A frailty index (scored from 0.0-1.0) based on deficits in health across multiple domains was created at all time-points; outcomes were mortality up to 15 years and femoral neck bone density.

RESULTS

At baseline, the proportion least frail, i.e., most robust (FI 0.0-0.1) constituted 48%, dropping to 25 and 14% at age 80 and 85. On average, over 10 years, the annual linear frailty score progression was approximately 6-7%. Among the least frail, 11% remained robust over 10 years. A higher frailty score was equivalent to being 5 to 10 years older. Mortality was substantially higher in the highest quartile compared to the lowest based on baseline frailty score; after 10 years, 48.7% had died vs 17.2% (p = 1.7 × 10^-14). Mortality risk over the first 5 years was highest in the frailest (Q4 vs Q1; HR_unadj 3.26 [1.86-5.73]; p < 0.001) and continued to be elevated at 10 years (HR_unadj 3.58 [2.55-5.03]; p < 0.001). Frailty was associated with BMD after adjusting for BMI (overall p = 0.006; Q1 vs Q4 p = 0.003).

CONCLUSIONS

The frailty index was highly predictive of mortality showing a threefold increased risk of death in the frailest both in a shorter and longer perspective. Only one in ten older women escaped progression after 10 years. Frailty and osteoporosis were associated.

Comparative analysis of the association between 35 frailty scores and cardiovascular events, cancer, and total mortality in an elderly general population in England: An observational study

BACKGROUND

Frail elderly people experience elevated mortality. However, no consensus exists on the definition of frailty, and many frailty scores have been developed. The main aim of this study was to compare the association between 35 frailty scores and incident cardiovascular disease (CVD), incident cancer, and all-cause mortality. Also, we aimed to assess whether frailty scores added predictive value to basic and adjusted models for these outcomes.

METHODS AND FINDINGS

Through a structured literature search, we identified 35 frailty scores that could be calculated at wave 2 of the English Longitudinal Study of Ageing (ELSA), an observational cohort study. We analysed data from 5,294 participants, 44.9% men, aged 60 years and over. We studied the association between each of the scores and the incidence of CVD, cancer, and all-cause mortality during a 7-year follow-up using Cox proportional hazard models at progressive levels of adjustment. We also examined the added predictive performance of each score on top of basic models using Harrell's C statistic. Using age of the participant as a timescale, in sex-adjusted models, hazard ratios (HRs) (95% confidence intervals) for all-cause mortality ranged from 2.4 (95% CI: 1.7-3.3) to 26.2 (95% CI: 15.4-44.5). In further adjusted models including smoking status and alcohol consumption, HR ranged from 2.3 (95% CI: 1.6-3.1) to 20.2 (95% CI: 11.8-34.5). In fully adjusted models including lifestyle and comorbidity, HR ranged from 0.9 (95% CI: 0.5-1.7) to 8.4 (95% CI: 4.9-14.4). HRs for CVD and cancer incidence in sex-adjusted models ranged from 1.2 (95% CI: 0.5-3.2) to 16.5 (95% CI: 7.8-35.0) and from 0.7 (95% CI: 0.4-1.2) to 2.4 (95% CI: 1.0-5.7), respectively. In sex- and age-adjusted models, all frailty scores showed significant added predictive performance for all-cause mortality, increasing the C statistic by up to 3%. None of the scores significantly improved basic prediction models for CVD or cancer. A source of bias could be the differences in mortality follow-up time compared to CVD/cancer, because the existence of informative censoring cannot be excluded.

CONCLUSION

There is high variability in the strength of the association between frailty scores and 7-year all-cause mortality, incident CVD, and cancer. With regard to all-cause mortality, some scores give a modest improvement to the predictive ability. Our results show that certain scores clearly outperform others with regard to three important health outcomes in later life. Finally, we think that despite their limitations, the use of frailty scores to identify the elderly population at risk is still a useful measure, and the choice of a frailty score should balance feasibility with performance.

Period prevalence, risk factors and consequent injuries of falling among the Saudi elderly living in Riyadh, Saudi Arabia: a cross-sectional study

OBJECTIVES

Approximately 28% to 35% of people aged 65 and over fall each year. The consequent injuries of falls are considered a major public health problem. Falls account for more than half of injury-related hospitalisations among old people. The aim of this study was to measure a 1-year period prevalence of falling among old people in Riyadh, Saudi Arabia. In addition, this study described the most common risk factors and consequent injuries of falls.

SETTING AND PARTICIPANTS

A cross-sectional survey was carried out in Riyadh, using a convenient sampling. The targeted population were Saudi citizens who were 60 years or above. Over a 6-month period, 1182 individuals were sampled (545 men and 637 women).

RESULTS

The 1-year prevalence of falling among old Saudis (>=60 years) was 49.9%. Our results show that 74% of the participants who experienced falls had postfall injuries. Old participants who were uneducated and those with middle school certification were associated with falls (adjusted OR (aOR) 1.72; 95% CI 1.15 to 2.56, aOR 1.81; 95% CI 1.15 to 2.85, respectively). Those who live in rented houses had a higher risk of falls. Interestingly, having a caregiver was significantly associated with more falls (aOR 1.39; 95% CI 1.08 to 1.79). However, not using any medications was significantly related to fewer falls. In addition, old individuals using walking aids were more likely to fall than those who did not. Participants who mentioned 'not having stressors were associated with less frequent falls (aOR 0.62; 95% CI 0.39 to 0.97). Cerebrovascular accidents were strongly associated with falls with an estimated OR of 2.75 (95% CI 1.18 to 6.43). Moreover, osteoporosis, poor vision and back pain were found to be predictors for falls among the elderly.

CONCLUSION

49.9% of elderly Saudis had experienced one or more falls during a 12-month period. Several preventable risk factors could be addressed by routine geriatric assessment. Research on the impact of these risk factors is needed.

A History of Falls is Associated with a Significant Increase in Acute Mortality in Women after Stroke

Background and Purpose

The risks of falls and fractures increase after stroke. Little is known about the prognostic significance of previous falls and fractures after stroke. This study examined whether having a history of either event is associated with poststroke mortality.

Methods

We analyzed stroke register data collected prospectively between 2003 and 2015. Eight sex-specific models were analyzed, to which the following variables were incrementally added to examine their potential confounding effects: age, type of stroke, Oxfordshire Community Stroke Project classification, previous comorbidities, frailty as indicated by the prestroke modified Rankin Scale score, and acute illness parameters. Logistic regression was applied to investigate in-hospital and 30-day mortality, and Cox proportional-hazards models were applied to investigate longer-term outcomes of mortality.

Results

In total, 10,477 patients with stroke (86.1% ischemic) were included in the analysis. They were aged 77.7±11.9 years (mean±SD), and 52.2% were women. A history of falls was present in 8.6% of the men (n=430) and 20.2% of the women (n=1,105), while 3.8% (n=189) of the men and 12.9% of the women (n=706) had a history of both falls and fractures. Of the outcomes examined, a history of falls alone was associated with increased in-hospital mortality [odds ratio (OR)=1.33, 95% confidence interval (CI)=1.03–1.71] and 30-day mortality (OR=1.34, 95% CI=1.03–1.73) in women in the fully adjusted models. The Cox proportional-hazards models for longer-term outcomes and the history of falls and fractures combined showed no significant results.

Conclusions

The history of falls is an important factor for acute stroke mortality in women. A previous history of falls may therefore be an important factor to consider in the short-term stroke prognosis, particularly in women.

Agreement Between 35 Published Frailty Scores in the General Population

In elderly populations, frailty is associated with higher mortality risk. Although many frailty scores (FS) have been proposed, no single score is considered the gold standard. We aimed to evaluate the agreement between a wide range of FS in the English Longitudinal Study of Ageing (ELSA). Through a literature search, we identified 35 FS that could be calculated in ELSA wave 2 (2004–2005). We examined agreement between each frailty score and the mean of 35 FS, using a modified Bland-Altman model and Cohen's kappa (κ). Missing data were imputed. Data from 5,377 participants (ages ≥60 years) were analyzed (44.7% men, 55.3% women). FS showed widely differing degrees of agreement with the mean of all scores and between each pair of scores. Frailty classification also showed a very wide range of agreement (Cohen's κ = 0.10–0.83). Agreement was highest among “accumulation of deficits”-type FS, while accuracy was highest for multidimensional FS. There is marked heterogeneity in the degree to which various FS estimate frailty and in the identification of particular individuals as frail. Different FS are based on different concepts of frailty, and most pairs cannot be assumed to be interchangeable. Research results based on different FS cannot be compared or pooled.

Defining Aging Phenotypes and Related Outcomes: Clues to Recognize Frailty in Hospitalized Older Patients

Background

Because frailty is a complex phenomenon associated with poor outcomes, the identification of patient profiles with different care needs might be of greater practical help than to look for a unifying definition. This study aimed at identifying aging phenotypes and their related outcomes in order to recognize frailty in hospitalized older patients.

Methods

Patients aged 65 or older enrolled in internal medicine and geriatric wards participating in the REPOSI registry. Relationships among variables associated to sociodemographic, physical, cognitive, functional, and medical status were explored using a multiple correspondence analysis. The hierarchical cluster analysis was then performed to identify possible patient profiles. Multivariable logistic regression was used to verify the association between clusters and outcomes (in-hospital mortality and 3-month postdischarge mortality and rehospitalization).

Results

2,841 patients were included in the statistical analyses. Four clusters were identified: the healthiest (I); those with multimorbidity (II); the functionally independent women with osteoporosis and arthritis (III); and the functionally dependent oldest old patients with cognitive impairment (IV). There was a significantly higher in-hospital mortality in Cluster II (odds ratio [OR] = 2.27, 95% confidence interval [CI] = 1.15-4.46) and Cluster IV (OR = 5.15, 95% CI = 2.58-10.26) and a higher 3-month mortality in Cluster II (OR = 1.66, 95% CI = 1.13-2.44) and Cluster IV (OR = 1.86, 95% CI = 1.15-3.00) than in Cluster I.

Conclusions

Using alternative analytical techniques among hospitalized older patients, we could distinguish different frailty phenotypes, differently associated with adverse events. The identification of different patient profiles can help defining the best care strategy according to specific patient needs.

Absence of association between frailty index and survival in elderly Brazilians: the FIBRA Study

In Brazil, the frailty index has not been evaluated previously for its capacity to predict mortality in community-dwelling elderly. The objective of the current study was to evaluate the association between frailty index and mortality in the elderly. This was a prospective study consisting of data from the FIBRA Network-2008-2009 in Campinas, São Paulo State, with information on community-dwelling older adults from the urban area and through the Mortality Information System. Comparisons and statistical associations were performed with the following tests: Mann-Whitney, Kruskal-Wallis, chi-square, and Cox regression with 95% confidence intervals. A total of 689 older adults participated 72.1 ± 5.3 years), of whom 68.8% were women. The prevalence rate for frailty was 38.8%, compared to 51.6% for pre-frailty and 9.6% for fit elders; overall mean frailty index was higher in women. There was no association between frailty index and chronological age. Cox regression showed that the variables age HR: 1.10; 95%CI: 1.05-1.15) and gender HR: 0.57; 95%CI: 0.33-0.99) were significantly associated with mortality. No association was found between frailty index and mortality HR: 3.02; 95%CI: 0.24-37.64). Frailty index was not capable of predicting mortality in community-dwelling elderly Brazilians.

Evaluation on the cost-effective threshold of osteoporosis treatment on elderly women in China using discrete event simulation model

This study used a simulation model to determine the cost-effective threshold of fracture risk to treat osteoporosis among elderly Chinese women. Osteoporosis treatment is cost-effective among average-risk women who are at least 75 years old and above-average-risk women who are younger than 75 years old.

INTRODUCTION

Aging of the Chinese population is imposing increasing economic burden of osteoporosis. This study evaluated the cost-effectiveness of osteoporosis treatment among the senior Chinese women population.

METHODS

A discrete event simulation model using age-specific probabilities of hip fracture, clinical vertebral fracture, wrist fracture, humerus fracture, and other fracture; costs (2015 US dollars); and quality-adjusted life years (QALYs) was used to assess the cost-effectiveness of osteoporosis treatment. Incremental cost-effectiveness ratio (ICER) was calculated. The willingness to pay (WTP) for a QALY in China was compared with the calculated ICER to decide the cost-effectiveness. To determine the absolute 10-year hip fracture probability at which the osteoporosis treatment became cost-effective, average age-specific probabilities for all fractures were multiplied by a relative risk (RR) that was systematically varied from 0 to 10 until the WTP threshold was observed for treatment relative to no intervention. Sensitivity analyses were also performed to evaluate the impacts from WTP and annual treatment costs.

RESULTS

In baseline analysis, simulated ICERs were higher than the WTP threshold among Chinese women younger than 75, but much lower than the WTP among the older population. Sensitivity analyses indicated that cost-effectiveness could vary due to a higher WTP threshold or a lower annual treatment cost. A 30 % increase in WTP or a 30 % reduction in annual treatment costs will make osteoporosis treatment cost-effective for Chinese women population from 55 to 85.

CONCLUSIONS

The current study provides evidence that osteoporosis treatment is cost-effective among a subpopulation of Chinese senior women. The results also indicate that the cost-effectiveness of using osteoporosis treatment is sensitive to the WTP threshold and annual treatment costs.

An overview of osteoporosis and frailty in the elderly

Osteoporosis and osteoporotic fractures remain significant public health challenges worldwide. Recently the concept of frailty in relation to osteoporosis in the elderly has been increasingly accepted, with emerging studies measuring frailty as a predictor of osteoporotic fractures. In this overview, we reviewed the relationship between frailty and osteoporosis, described the approaches to measuring the grades of frailty, and presented current studies and future research directions investigating osteoporosis and frailty in the elderly. It is concluded that measuring the grades of frailty in the elderly could assist in the assessment, management and decision-making for osteoporosis and osteoporotic fractures at a clinical research level and at a health care policy level.