Association between Insulin-Like Growth Factor-1 and Frailty among Older Adults

Prevalence and risk factors of frailty in older patients with coronary heart disease: A systematic review and meta-analysis

OBJECTIVE

To quantitatively synthesise evidence on the prevalence of and risk factors of frailty in older patients with coronary heart disease.

METHODS

Nine electronic databases were searched from the inception to July 20th 2024. Random-effects model was performed to calculate to estimate the prevalence of frailty in older patients with coronary heart disease. Meta-regression analysis and subgroup analysis were conducted to explore the potential sources of heterogeneity. Sensitivity analysis was conducted using a study-by-study exclusion method. Meta-analysis of risk factors was performed using the Mantel-Haenszel or inverse variance method and only on the risk factors that have been reported in a minimum of two studies.

RESULTS

A total of 42 studies from 5 countries met the inclusion criteria, involving 11954 older patients. The pooled prevalence in older adults with coronary heart disease was 36% (95%CI: 31%-40%) for frailty. We found a higher prevalence of frailty among older patients with coronary heart disease in females, ≥80 years, case-control studies, EFS evaluation tool and acute coronary syndrome. Age, female, cardiac classification, malnutrition, fall within 1 year, sleep disorder, hypoproteinemia (albumin<35g/L), low level of literacy, depression, anxiety, low BMI, polypharmacy, comorbidities, CCI, diabetes, hypertension, high level of BNP, ADL disability, gait speed, living alone, low level of 25(OH)D3 were risk factors of frailty among older patients with coronary heart disease.

CONCLUSIONS

Coronary heart disease patients have a significantly higher prevalence of frailty. Early screening and timely prevention of frailty by medical practitioners are needed to provide more targeted measures for CHD patients.

Insulin-like Growth Factor-1 Levels Reflect Muscle and Bone Health and Determine Complications and Mortality in Decompensated Cirrhosis

Background

The growth hormone-insulin-like growth factor (GH-IGF-1) axis and its impairment with sarcopenia, frailty, bone health, complications, and prognosis are not well characterized in cirrhosis.

Methods

We investigated the adult decompensated cirrhosis out-patients at a tertiary care institute between 2021 and 2023 for serum GH and IGF-1 levels, and associated them with sarcopenia (CT-SMI in cm2/m2), liver frailty index (LFI), osteodystrophy (DEXA), clinical decompensations (overall, ascites, encephalopathy, infection, and bleed), and survival up to 180 days.

Results

One-hundred-seventy-two patients, 95% males, aged 46.5 years (median). logIGF-1 levels were negatively associated with sarcopenia, osteodystrophy, LFI, CTP, and MELD-Na score (P < 0.05 each). Patients with low IGF-1 levels had a higher incidence of complications (overall, ascites and encephalopathy) than those with intermediate, and high IGF-1 levels (P < 0.05 each). Both logIGF-1 (AUC: 0.686) and MELD (AUC: 0.690) could predict 180-day mortality (P < 0.05, each). Adding logIGF-1 with MELDNa further improved discriminative accuracy of MELDNa (AUC: 0.729) P < 0.001. The increase in IGF-1 on follow-up was associated with better survival and fewer complications.

Conclusion

Reduced IGF-1 levels reflect sarcopenia, frailty, and osteodystrophy in cirrhosis. Low IGF-1 are associated with severity, development of decompensations, and mortality.

Scale-based screening and assessment of age-related frailty

As the population ages, the prevalence of age-related frailty increases sharply, which increases the risk of poor health status of older adults, such as disability, falls, hospitalization, and death. Across the globe, frailty is moving toward the forefront of health and medical research. Currently, frailty is believed to be preventable and reversible, so the early identification of frailty is critical. However, there are neither precise biomarkers of frailty nor definitive laboratory tests and corresponding clinical testing techniques and equipment in clinical practice. As a result, the clinical identification of frailty is mainly achieved through the widely used frailty scale, which is an objective, simple, time-saving, effective, economical, and feasible measurement tool. In this narrative review, we summarized and analyzed the various existing frailty scales from different perspectives of screening and evaluation, aiming to provide a reference for clinical researchers and practitioners to judge and manage frail older people accurately.

Assessing the causal relationship between frailty and sex hormone-binding globulin or insulin-like growth factor-1 levels: A sex-stratified bidirectional Mendelian Randomization study

BACKGROUND

The association between frailty and sex hormone-binding globulin (SHBG) or insulin-like growth factor-1(IGF-1) levels demonstrates sex differences with inconsistent conclusions. This study aims to explore the causal relationship between frailty and SHBG or IGF-1 levels through bidirectional Mendelian randomization (MR).

METHODS

We conducted two-sample bidirectional sex-stratified MR analyses using summary-level data from genome-wide association studies (GWASs) to examine the causal relationship between frailty and IGF-1 or SHBG levels, as measured by frailty index (FI) and frailty phenotype (FP). We use the random-effects inverse-variance weighted (IVW), weighted median, MR-Egger, MR-Egger intercept, and leave-one-out approaches.

RESULT

The relationship between frailty and SHBG or IGF-1 levels is inversely related, with a significant decrease in SHBG levels in females. Specifically, SHBG levels significantly decrease with FI (β = -5.49; 95 % CI: -9.67 to -1.32; FDR = 0.02) and more pronounced with FP (β = -10.14; 95 % CI: -16.16 to -4.13; FDR = 0.01), as determined by the IVW approach. However, reverse analysis shows no significant effect of IGF-1 or SHBG levels on either FI or FP (p > 0.05).

CONCLUSION

Our study indicates a negative correlation between frailty and the levels of SHBG and IGF-1. It is suggested that further research is required to establish cut-off values for SHBG and IGF-1 levels in the frailty population. This is particularly important for females at higher risk, such as those undergoing menopause, to enable comprehensive assessment and early prevention efforts. While the findings imply that reduced IGF-1 and SHBG levels may not directly contribute to frailty, it is important not to overlook the underlying mechanisms through which they may indirectly influence frailty.

Frailty detection with routine blood tests using data from the english longitudinal study of ageing (ELSA)

PURPOSE

Frailty is a rising global health issue in ageing society. Easily accessible and sensitive tools are needed for frailty monitoring while routine blood factors can be potential candidates.

METHODS

Data from 1907 participants (aged 60 years or above) were collected from the 4th to 9th wave of the English longitudinal study of ageing. 14 blood factors obtained from blood tests were included in the analysis. A 52-item frailty index (FI) was calculated for frailty evaluation. Logistic regression and Cox proportional hazards analysis were used to explore the relationships between baseline blood factors and the incidence of frailty over time respectively. All analyses were controlled for age and sex.

RESULTS

The mean age of participants was 67.3 years and 47.2% of them were male. Our study identified that 8 blood factors (mean corpuscular haemoglobin, HDL, triglyceride, ferritin, hsCRP, dehydroepiandrosterone, haemoglobin, and WBC) involved in inflammatory, nutritional and metabolic processes were associated with frailty. The combined model with these 8 blood factors had an AUC of 0.758 at cross-sectional level. In the Cox proportional hazards analysis, higher triglyceride (HR: 1.30, 95%CI: 1.07 ~ 1.59), WBC (HR: 1.16, 95%CI: 1.05 ~ 1.28), and lower HDL (HR: 0.58, 95%CI: 0.38 ~ 0.90) at baseline were linked to greater risk of developing frailty within 10 years. Compared to adults without abnormal blood factors at baseline, the hazard ratios of participants with two or more abnormal blood factors were almost twofold higher in developing frailty over time.

CONCLUSIONS

Routine blood factors, particularly triglyceride, HDL and WBC, could be used for frailty screening in clinical practice and estimate the development of frailty over time.

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.

Are Skeletal Muscle Changes during Prolonged Space Flights Similar to Those Experienced by Frail and Sarcopenic Older Adults?

Microgravity exposure causes several physiological and psychosocial alterations that challenge astronauts' health during space flight. Notably, many of these changes are mostly related to physical inactivity influencing different functional systems and organ biology, in particular the musculoskeletal system, dramatically resulting in aging-like phenotypes, such as those occurring in older persons on Earth. In this sense, sarcopenia, a syndrome characterized by the loss in muscle mass and strength due to skeletal muscle unloading, is undoubtedly one of the most critical aging-like adverse effects of microgravity and a prevalent problem in the geriatric population, still awaiting effective countermeasures. Therefore, there is an urgent demand to identify clinically relevant biological markers and to underline molecular mechanisms behind these effects that are still poorly understood. From this perspective, a lesson from Geroscience may help tailor interventions to counteract the adverse effects of microgravity. For instance, decades of studies in the field have demonstrated that in the older people, the clinical picture of sarcopenia remarkably overlaps (from a clinical and biological point of view) with that of frailty, primarily when referred to the physical function domain. Based on this premise, here we provide a deeper understanding of the biological mechanisms of sarcopenia and frailty, which in aging are often considered together, and how these converge with those observed in astronauts after space flight.

Frailty biomarkers under the perspective of geroscience: A narrative review

Cellular and molecular aging biomarkers might contribute to identify at-risk individuals for frailty before overt clinical manifestations appear. Although studies on the associations of aging biomarkers and frailty exist, no investigation has gathered this information using a structured framework for identifying aging biomarkers; as a result, the evidence on frailty and aging biomarkers is diffuse and incomplete. Therefore, this narrative review aimed to gather information on the associations of the hallmarks of aging and frailty under the perspective of geroscience. The literature on human studies on this topic is sparse and mainly composed of cross-sectional investigations performed in small study samples. The main putative aging biomarkers associated to frailty were: mitochondrial DNA copy number (genomic instability and mitochondrial dysfunction), telomere length (telomere attrition), global DNA methylation (epigenetic alterations), Hsp70 and Hsp72 (loss of proteostasis), IGF-1 and SIRT1 (deregulated nutrient-sensing), GDF-15 (mitochondrial dysfunction, cellular senescence and altered intercellular communication), CD4 + and CD8 + cell percentages (cellular senescence), circulating osteogenic progenitor (COP) cells (stem cell exhaustion), and IL-6, CRP and TNF-alpha (altered intercellular communication). IGF-1, SIRT1, GDF-15, IL-6, CRP and TNF-alpha presented more evidence among these biomarkers, highlighting the importance of inflammation and nutrient sensing on frailty. Further longitudinal studies investigating biomarkers across the hallmarks of aging would provide valuable information on this topic.

Association between Bone-Related Physiological Substances and Oral Function in Community-Dwelling Older People

BACKGROUND

Oral dysfunction is related to long-term cares including activities of daily living. The objective of this study was to determine the association between oral function and the bone-related physiological substances osteocalcin (OC) and insulin-like growth factor-1 (IGF-1).

METHODS

The study participants were 139 community-dwelling older people in Japan. Evaluation of oral dysfunction was based on subjective judgment by each participant. Blood analysis included OC, IGF-1, and albumin.

RESULTS

Univariate and multiple logistic analyses showed that IGF-1 was significantly associated with a "decline in masticatory function" (p = 0.0074 and p = 0.0308, respectively). Receiver operating characteristic curve analysis of IGF-1 levels revealed a threshold score of 108 ng/mL (p < 0.01) for discriminating a "decline in masticatory function". Logistic regression analysis revealed that participants with an IGF-1 level ≤108 ng/mL had an odds ratio of 4.31 (p < 0.05) for a "decline in masticatory function". No significant association was found between the OC level and oral dysfunction.

CONCLUSIONS

These results suggest a possible relationship between lower serum IGF-1 levels and a decline in masticatory dysfunction in community-dwelling older people.

Association between serum insulin-like growth factor 1 and locomotive syndrome in community-dwelling older people

Background

Locomotive syndrome (LS) is a condition in which mobility decreases, and it is known as a risk factor for elderly persons needing care in connection with sarcopenia and frailty. Prevention or delay of the onset of these diseases is important for preventing the need for care, and identification of biomarkers as indicators for appropriate intervention is useful. The present study aimed to clarify whether the serum insulin-like growth factor 1 (IGF-1) level, which has been reported to be related to sarcopenia and frailty, is related to LS.

Methods

The study participants were 133 elderly people living in a rural area in Japan. LS was assessed using Locomo-25, which is a self-administered questionnaire, and LS was defined as a Locomo-25 score ≥ 7 points. Serum IGF-1 and albumin levels were measured. A self-completed medical history questionnaire was used.

Results

On multiple linear regression analysis, age, IGF-1, osteoporosis, and osteoarthritis were significantly associated with the Locomo-25 score. The receiver-operating characteristic curve analysis of the IGF-1 level showed a threshold value of 82.0 ng/mL for discriminating non-LS and LS. The logistic regression analysis adjusted for osteoporosis, osteoarthritis, and the propensity score estimated from sex, age, and BMI showed that the odds ratio (OR) of the IGF-1 level for LS was 1.019 (95% confidence interval [CI], 1.002–1.039; p = 0.027), and the OR of IGF-1 ≤ 82 ng/mL for LS was 2.275 (95% CI 0.993–5.324; p = 0.052).

Conclusions

The present findings suggest that osteoporosis and osteoarthritis were associated with early LS, and a decrease of the serum IGF-1 level was a significant independent factor for early LS.

Differences in cognitive function, cardiorespiratory fitness and BDNF concentration in physically active CHD patients vs healthy controls

BACKGROUND

Coronary heart disease (CHD) is frequently associated with cognitive impairment (CI), whereas physical exercise may improve cognition. To date, the cognitive profile of physically active CHD patients remains poorly understood. Physical activity and cognition has been associated with neurotrophic biomarkers that are positively modulated by a higher cardiorespiratory fitness (V̇ O₂peak) and/or active lifestyle. This study aimed to compare the cognitive functions, V̇ O₂peak and trophic biomarkers in physically active CHD patients vs healthy controls.

METHODS

Thirty-nine CHD patients and 20 controls performed a cardiopulmonary exercise test, a neuropsychological assessment (short-term and working memory, processing speed, executive functions, and long-term verbal memory), and a blood draw to measure brain-derived neurotrophic factor (BDNF), insulin-like growth factor-1 (IGF1), and cathepsin B (CTSB) plasma concentrations. Physical activity was also measured with an accelerometer for 1 week.

RESULTS

Compared to controls, CHD patients had lower V̇ O₂peak (22.2 vs 29.3 mL/min/kg, p<0.001), but similar moderate to vigorous physical activity levels (27.5 vs 34.4 min/day, p=0.114). CHD patients had poorer performances for executive functions (0.198 vs -0.370, p=0.004) and processing speed (0.150 vs -0.293, p=0.025), as well as lower BDNF concentrations (166.4 vs 300.2 ng/ml, p=0.027), but similar IGF-1 and CTSB concentrations (p>0.05) when compared to controls. BDNF was an independent predictor of processing speed in CHD, and IGF-1 and BDNF were independent predictors of verbal memory in healthy controls.

CONCLUSION

Despite similar physical activity levels, fit CHD patients had lower V̇ O₂peak values, cognitive performances (executive functions and processing speed) and BDNF concentrations when compared to controls.

Physiological Systems in Promoting Frailty

Frailty is a complex syndrome affecting a growing sector of the global population as medical developments have advanced human mortality rates across the world. Our current understanding of frailty is derived from studies conducted in the laboratory as well as the clinic, which have generated largely phenotypic information. Far fewer studies have uncovered biological underpinnings driving the onset and progression of frailty, but the stage is set to advance the field with preclinical and clinical assessment tools, multiomics approaches together with physiological and biochemical methodologies. In this article, we provide comprehensive coverage of topics regarding frailty assessment, preclinical models, interventions, and challenges as well as clinical frameworks and prevalence. We also identify central biological mechanisms that may be at play including mitochondrial dysfunction, epigenetic alterations, and oxidative stress that in turn, affect metabolism, stress responses, and endocrine and neuromuscular systems. We review the role of metabolic syndrome, insulin resistance and visceral obesity, focusing on glucose homeostasis, adenosine monophosphate-activated protein kinase (AMPK), mammalian target of rapamycin (mTOR), and nicotinamide adenine dinucleotide (NAD+ ) as critical players influencing the age-related loss of health. We further focus on how immunometabolic dysfunction associates with oxidative stress in promoting sarcopenia, a key contributor to slowness, weakness, and fatigue. We explore the biological mechanisms involved in stem cell exhaustion that affect regeneration and may contribute to the frailty-associated decline in resilience and adaptation to stress. Together, an overview of the interplay of aging biology with genetic, lifestyle, and environmental factors that contribute to frailty, as well as potential therapeutic targets to lower risk and slow the progression of ongoing disease is covered. © 2022 American Physiological Society. Compr Physiol 12:1-46, 2022.

C-Reactive Protein and Frailty in Heart Failure

Frailty commonly coexists with heart failure and although both have been associated with neurohormonal dysregulation, inflammation, catabolism, and skeletal muscle dysfunction, there are still no defined biomarkers to assess frailty, especially from the perspective of populations with cardiovascular diseases. This is a cross-sectional study with 106 outpatients with heart failure, aged ≥60 years, which aimed to assess frailty through a physical (frailty phenotype) and multidimensional (Tilburg Frailty Indicator) approach and to analyze its association with inflammatory and humoral biomarkers (high sensitivity C-reactive protein [hs-CRP], interleukin 6, tumor necrosis factor-α, insulin-like growth factor-1, and total testosterone), clinical characteristics, and functional capacity. In univariate analysis, hs-CRP was associated with frailty in both phenotype and Tilburg Frailty Indicator assessment (PR = 1.005, 95% confidence interval [CI] 1.001 to 1.009, p = 0.027 and PR = 1.015, 95% CI 1.006 to 1.024, p = 0.001, respectively), which remained significant in the final multivariate model in the frailty assessment by the phenotype (PR = 1.004, 95% CI 1.001 to 1.008, p = 0.025). There was no statistically significant difference between the groups for other biomarkers analyzed. Frailty was also associated with worse functional capacity, nonoptimized pharmacological treatment and a greater number of drugs in use, age, female gender, and a greater number of comorbidities. In conclusion, frailty is associated with higher levels of hs-CRP, which can indicate it is a promising frailty biomarker.

Consistent patterns in the inconsistent associations of Insulin-like growth factor 1 (IGF-1), C-Reactive Protein (C-RP) and Interleukin 6 (IL-6) levels with delirium in surgical populations. A systematic review and meta-analysis

BACKGROUND

Biomarkers for delirium could increase diagnostic accuracy and may help to identify pathological pathways. Until now study findings concerning cytokine levels have been inconsistent.

AIMS

Systematic review and meta-analysis investigating the association between peripheral levels of Insulin-like Growth Factor-1 (IGF-1), C-Reactive Protein (C-RP) and Interleukin-6 (IL-6) and delirium in surgical patients, and to explore if there are distinct/specific patterns that may potentially explain inconsistent results.

METHODS

PubMed, Scopus, CINAHL, Cochrane, and EMBASE databases were searched. Inclusion criteria were: prospective studies, surgical populations excluding preoperative delirium, available data. The following were collected: type of operation (orthopaedic, abdominal, etc), the timing of operation (acute, elective, both), demographics, number of participants with delirium, time of preoperative blood withdrawal, and preoperative levels of each biomarker.

RESULTS

Low levels of IGF-1 (n = 7 studies) are significantly associated with post-operative delirium in abdominal surgical samples. High levels of C-RP (n = 9) are associated with delirium in acute orthopaedic and elective abdominal operations. IL-6 (n = 14) is a significant predictor of post-operative delirium in a variety of surgical conditions (elective or acute).

DISCUSSION

A common pattern exists in the otherwise conflicting reported findings. This similarity may reflect different underling mechanisms and predisposing factors like cachexia and catabolic stages. It seems that delirium in abdominal surgery is triggered by IGF-1 disturbances, while in other surgeries by an inflammatory reaction.

CONCLUSIONS

Despite the contradictory results concerning the association of IGF-1, C-RP and IL-6 with postoperative delirium, the present meta-analysis shows that there are certain patterns. IL-6 seems a consistent predictor for delirium in surgical samples.

Association between insulin growth factor-1, bone mineral density, and frailty phenotype in children with chronic kidney disease

BACKGROUND

This cohort study investigates the association between insulin growth factor-1 (IGF-1), bone mineral density, and frailty phenotype in children with chronic kidney disease (CKD).

METHODS

Forty-six patients (median age 14.5 years) were prospectively enrolled. Frailty phenotype was defined as the presence ≥ 3 of the following indicators: suboptimal growth/weight gain (body mass index height age < 5th percentile or height < 3rd percentile or loss of ≥ 10 percentiles/year in at least one parameter), low muscle mass (lean tissue mass height age < 5th percentile or loss of ≥ 10 percentiles/year), general fatigue reported by parent or child, and C-reactive protein > 3 mg/l. Lumbar bone mineral apparent density (LBMAD) was measured by dual-energy X-ray absorptiometry, body composition by bioimpedance spectroscopy, and IGF-1 by enzyme-labeled chemiluminescent immunometric assay.

RESULTS

Frailty phenotype (seven patients) was more frequent in advanced CKD (estimated glomerular filtration rate < 30 ml/min/1.73m²) (p = 0.014). IGF-1 and LBMAD z-scores were lower in patients with suboptimal growth/weight gain (14 patients) (p = 0.013, p = 0.012), low muscle mass (nine patients) (p = 0.001, p = 0.009), and general fatigue (eight patients) (p < 0.001, p = 0.004). IFG-1 and LBMAD z-scores were associated with frailty phenotype (OR 0.109, 95% CI 0.015-0.798 and OR 0.277, 95% CI 0.085-0.903) after adjustment for CKD stage. IGF-1 z-score was associated with LBMAD < 5th percentile (six patients) (OR 0.020, 95% CI 0.001-0.450) after adjustment for CKD stage. The association between LBMAD and frailty phenotype lost significance after adjustment for IGF-1.

CONCLUSION

Frailty phenotype is more frequent in advanced pediatric CKD. IGF-1 is negatively associated with frailty phenotype and interferes in the association between frailty and LBMAD.

How gait influences frailty models and health-related outcomes in clinical-based and population-based studies: a systematic review

Aging is often associated with a decline in physical function that eventually leads to loss of autonomy in activities of daily living (ADL). Walking is a very common ADL, important for main determinants of quality of life in older age, and it requires the integration of many physiological systems. Gait speed has been described as the 'sixth vital sign' because it is a core indicator of health and function in aging and disease. We reviewed original studies up to June 2020 that assessed frailty in both longitudinal and cross-sectional observational studies, paying particular attention to how gait is measured in older population and how the gait parameter adopted may influence the estimated frailty models and the health-related outcomes of the various studies (i.e. clinical, cognitive, physical, and nutritional outcomes). Eighty-five studies met the search strategy and were included in the present systematic review. According to the frailty tools, more than 60% of the studies used the physical phenotype model proposed by Fried and colleagues, while one-third referred to multi-domain indexes or models and only 5% referred to other single-domain frailty models (social or cognitive). The great heterogeneity observed in gait measurements and protocols limited the possibility to directly compare the results of the studies and it could represent an important issue causing variability in the different outcome measures in both clinical-and population-based settings. Gait appeared to be an indicator of health and function also in frail older adults, and different gait parameters appeared to predict adverse health-related outcomes in clinical, cognitive, and physical domains and, to a lesser extent, in nutritional domain. Gait has the potential to elucidate the common basic mechanisms of cognitive and motor decline. Advances in technology may extend the validity of gait in different clinical settings also in frail older adults, and technology-based assessment should be encouraged. Combining various gait parameters may enhance frailty prediction and classification of different frailty phenotypes.

Impacts of frailty on health care costs among community-dwelling older adults: A meta-analysis of cohort studies

BACKGROUND

The demands for health care services from the frail elderly individuals in the community continue to increase, which will exert a tremendous burden on health care costs. However, little is known regarding the magnitude of these impacts. In this study, we performed a systematic review and meta-analysis of the evidence to explore the impact of frailty on health care costs among community-dwelling older adults.

MATERIALS AND METHODS

Relevant published articles were searched from PubMed, Embase, Web of Science, the Cochrane Library, China National Knowledge Infrastructure (CNKI), Chinese Science and Technology Journal Full-text Database (VIP), Wanfang Database, Chinese Biomedical Literature Database (CBM), and the reference lists of articles. Published cohort or cross-sectional studies assessing the impacts of frailty on health care costs among community-dwelling older adults were identified (to June 2020). The outcomes on health care costs before and after baseline were stratified by frailty status.

RESULTS

A total of 7 cohort studies comprised of a total of 3,750,611 participants were included in our study. Our analyses showed that: (1) compared with the robust group, health care costs increased by $79-13,423.83 (standardized mean difference, SMD = 0.22, 95% Confidence interval, 95% CI, 0.22-0.22; P < 0.00001) in the pre-frail elderly and by $616-32,549.96 (SMD = 0.55, 95% CI, 0.44-0.67; P < 0.00001) in the frail elderly in the community. A significantly higher in the increase of health care costs was observed in the frail group compared with the pre-frail group(SMD = 0.35, 95% CI, 0.19-0.51; P < 0.0001); (2) the frailty phenotype components increased the health care costs of the elderly in community (weight loss: $1,630-6,209, SMD = 0.43, 95% CI, 0.17-0.69; P = 0.001; weakness: $275-7,586, SMD = 0.24, 95% CI, 0.08-0.40; P = 0.001; exhaustion: $1,545-10,559, SMD = 0.31, 95% CI, 0.13-0.49; P = 0.0006; slowness: $352-1,1891, SMD = 0.40, 95% CI = 0.14-0.65; P = 0.003; low physical activity: $512-3,459, SMD = 0.26, 95% CI, 0.16-0.36; P < 0.00001); (3) the increase in the frailty index was parallel with the increase in health care costs by $12,363-21,066 (SMD = 0.41, 95% CI, 0.29-0.53; P < 0.00001).

CONCLUSIONS AND IMPLICATIONS

This study revealed the adverse economic impacts of frailty status, frailty phenotype components, and frailty index on health care costs in community-dwelling older adults. Future research is warranted to investigate costs incurred by interventions to improve frailty, which will provide further insights into additional health care costs due to frailty.

Mortality in malnourished older adults diagnosed by ESPEN and GLIM criteria in the SarcoPhAge study

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) criteria have been recently launched by consensus of the major nutrition societies. GLIM criteria are partly constructed on the previous definition of malnutrition developed by the European Society of Clinical Nutrition and Metabolism (ESPEN). We aimed to assess malnutrition according to the ESPEN and GLIM criteria at baseline and to determine the corresponding risk of mortality during a 4-year follow-up in community-dwelling older adults from the SarcoPhAge (Sarcopenia and Physical Impairment with advancing Age) study. The relationship between malnutrition and incidence of 4-year adverse health consequences (institutionalization, hospitalization, falls, and fractures) was assessed.

METHODS

This prospective population-based cohort was part of SarcoPhAge, which included 534 older adults in Belgium, followed up from 2013 to 2019. Community-dwelling healthy volunteers ≥65 years old were recruited. Mortality and adverse health consequences were collected annually by interview or phone call. Baseline malnutrition was defined according to the GLIM and ESPEN criteria. Agreement between the two definitions was reported by Cohen's kappa coefficient. Adjusted Cox regression and Kaplan-Meier survival curves were performed for malnutrition. Logistic regression was used for the other outcomes.

RESULTS

From 534 subjects in SarcoPhAge, the records for 411 participants (73.2 ± 6.05 years old; 55.7% women) had all the variables needed to apply the GLIM criteria. Prevalence of baseline malnutrition was 23.4% for GLIM and 7% for ESPEN criteria (k = 0.30, low agreement). The adjusted Cox regression showed a significant increased mortality risk according to malnutrition status as defined by the GLIM [adjusted hazard ratio = 4.41 (95% confidence interval: 2.17-8.97)] and ESPEN [adjusted hazard ratio = 2.76 (95% confidence interval: 1.16-6.58)] criteria. Survival curves differed significantly between malnourished and non-malnourished groups, regardless of the definition used (log rank P < 0.001 for both). No association was found between baseline malnutrition according to these two criteria and 4-year risk of institutionalization, hospitalization, falls, or fractures (all P > 0.05).

CONCLUSIONS

Malnutrition according to the GLIM criteria was associated with a 4.4-fold higher mortality risk, double that of the ESPEN criteria, during a 4-year follow-up. No association was found between malnutrition according to these two criteria and incidence of other health adverse consequences. GLIM criteria anticipate mortality and might guide interventions, with important implications for clinical practice and research.

Nutrition Mediates the Relationship between Osteosarcopenia and Frailty: A Pathway Analysis

Osteosarcopenia is associated with increased risk of adverse outcomes such as falls and fractures. Its association with frailty is less well-described, particularly in independent community-dwelling older adults. Although nutrition plays a crucial role in maintaining bone and muscle health, the complex relationship between osteosarcopenia and nutrition in the pathogenesis of frailty remains to be elucidated. In this cross-sectional analysis of 230 independent, community-dwelling individuals (mean age 67.2 ± 7.4 years), we examined the associations between osteosarcopenia with nutritional status and frailty, and the mediating role of nutrition in the association between osteosarcopenia and frailty. Osteosarcopenia was defined as fulfilling both the Asian Working Group for Sarcopenia 2019 consensus definition (low relative appendicular skeletal muscle mass adjusted for height, in the presence of either of either low handgrip strength or slow gait speed) and T-score ≤ -2.5 SD on bone mineral densitometry. We assessed frailty using the modified Fried criteria and nutrition using the Mini-Nutritional Assessment. We performed multiple linear regression, followed by pathway analysis to ascertain whether nutrition mediates the relationship between osteosarcopenia and frailty. Our study population comprised: 27 (11.7%) osteosarcopenic, 35 (15.2%) sarcopenic, 36 (15.7%) osteoporotic and 132 (57.4%) normal (neither osteosarcopenic, sarcopenic nor osteoporotic). Osteosarcopenia (β = 1.1, 95% CI 0.86-1.4) and sarcopenia (β = 1.1, 95% CI 0.90-1.4) were significantly associated with frailty, but not osteoporosis. Nutrition mediated the association between osteosarcopenia and frailty (indirect effect estimate 0.09, bootstrap 95% CI 0.01-0.22). In conclusion, osteosarcopenia is associated with frailty and poorer nutritional status, with nutrition mediating the association between osteosarcopenia and frailty. Our findings support early nutritional assessment and intervention in osteosarcopenia to mitigate the risk of frailty.

Effects of Progressive Resistance Training on Cognition and IGF-1 Levels in Elder Women Who Live in Areas with High Air Pollution

The aim of this study was to determine the effects of a muscular strength programme on the levels of insulin-like growth factor-1 (IGF-1) and cognitive status in elder women with mild cognitive impairment who lived in areas of high air pollution. A total of 157 women participated in the study, distributed in four groups: Active/Clean (AC n = 38) and Active/Pollution (AP n = 37), who carried out a progressive resistance training programme for 24 months, and Sedentary/Clean (SC n = 40) and Sedentary/Pollution (SP n = 42). Maximum strength in the upper and lower limbs (1RM), cognition (Mini-Mental Scale Examination (MMSE)) and blood IGF-1 were evaluated. At the beginning of the intervention, there were no differences between the groups in the assessed variables. The active groups which carried out the resistance training programme (AC and AP), registered better results in IGF-1 than the sedentary groups. These differences were statistically significant in AC vs. SC (p < 0.01) and AP vs. SC (p < 0.05). Regarding MMSE, group AC registered the highest score increases (+8.2%) (significantly better than the other groups), while group SP worsened (−7%) significantly compared to the other three groups. In conclusion, resistance training had a positive effect on IGF-1, while sedentary behaviour and air pollution had a negative effect on cognitive status.

Physical activity and exercise: Strategies to manage frailty

Frailty, a consequence of the interaction of the aging process and certain chronic diseases, compromises functional outcomes in the elderly and substantially increases their risk for developing disabilities and other adverse outcomes. Frailty follows from the combination of several impaired physiological mechanisms affecting multiple organs and systems. And, though frailty and sarcopenia are related, they are two different conditions. Thus, strategies to preserve or improve functional status should consider systemic function in addition to muscle conditioning. Physical activity/exercise is considered one of the main strategies to counteract frailty-related physical impairment in the elderly. Exercise reduces age-related oxidative damage and chronic inflammation, increases autophagy, and improves mitochondrial function, myokine profile, insulin-like growth factor-1 (IGF-1) signaling pathway, and insulin sensitivity. Exercise interventions target resistance (strength and power), aerobic, balance, and flexibility work. Each type improves different aspects of physical functioning, though they could be combined according to need and prescribed as a multicomponent intervention. Therefore, exercise intervention programs should be prescribed based on an individual's physical functioning and adapted to the ensuing response.

Understanding the Physiological Links Between Physical Frailty and Cognitive Decline

Declines in both physical and cognitive function are associated with increasing age. Understanding the physiological link between physical frailty and cognitive decline may allow us to develop interventions that prevent and treat both conditions. Although there is significant epidemiological evidence linking physical frailty to cognitive decline, a complete understanding of the underpinning biological basis of the two disorders remains fragmented. This narrative review discusses insights into the potential roles of chronic inflammation, impaired hypothalamic-pituitary axis stress response, imbalanced energy metabolism, mitochondrial dysfunction, oxidative stress, and neuroendocrine dysfunction linking physical frailty with cognitive decline. We highlight the importance of easier identification of strategic approaches delaying the progression and onset of physical frailty and cognitive decline as well as preventing disability in the older population.

Frailty assessment: from clinical to radiological tools

Frailty is a syndrome of cumulative decline across multiple physiological systems, which predisposes vulnerable adults to adverse events. Assessing vulnerable patients can potentially lead to interventions that improve surgical outcomes. Anaesthesiologists who care for older patients can identify frailty to improve preoperative risk stratification and subsequent perioperative planning. Numerous clinical tools to diagnose frailty exist, but none has emerged as the standard tool to be used in clinical practice. Radiological modalities, such as computed tomography and ultrasonography, are widely performed before surgery, and are therefore available to be used opportunistically to objectively evaluate surrogate markers of frailty. This review presents the importance of frailty assessment by anaesthesiologists; lists common clinical tools that have been applied; and proposes that utilising radiological imaging as an objective surrogate measure of frailty is a novel, expanding approach for which anaesthesiologists can significantly contribute to broad implementation.

Serum Myostatin and IGF-1 as Gender-Specific Biomarkers of Frailty and Low Muscle Mass in Community-Dwelling Older Adults

OBJECTIVES

(i) To investigate serum myostatin (absolute and normalized for total body lean mass (TBLM)) and IGF-1 as biomarkers of frailty and low relative appendicular skeletal muscle mass (RASM) in older adults, and; (ii) to examine gender differences in the association of serum myostatin and IGF-1 levels with frailty and low RASM.

DESIGN

Cross-sectional study.

SETTING

The "Longitudinal Assessment of Biomarkers for characterization of early Sarcopenia and predicting frailty and functional decline in community-dwelling Asian older adults Study" (GERI-LABS) study in Singapore.

PARTICIPANTS

200 subjects aged 50 years and older residing in the community.

MEASUREMENTS

Frailty was assessed using the modified Fried criteria. Low RASM was defined using cutoffs for height-adjusted appendicular skeletal muscle mass measured by dual-energy X-ray absorptiometry as recommended by the Asian Working Group for Sarcopenia. Comorbidities, cognitive and functional performance, physical activity and nutritional status were assessed. Blood samples collected included serum myostatin, insulin-like growth factor 1 (IGF-1) and markers of inflammation (total white cell count, CRP, IL-6 and TNFaR1). Subjects were classified into 4 groups: Frail/Prefrail with low RASM (Frail/Low RASM), Frail/Prefrail with normal RASM (Frail/Normal RASM), Robust with low RASM (Robust/Low RASM) and Robust with normal RASM (Robust/Normal RASM).

RESULTS

63 (32%) subjects were classified as Frail/Low RASM, 53 (27%) Frail/Normal RASM, 28 (14%) Robust/Low RASM and 56 (28%) Robust/Normal RASM respectively. Frail/Low RASM subjects were older and had lower BMI compared to Frail/Normal RASM and robust subjects. Mean (SE) normalized myostatin levels were higher in Frail/Low RASM compared to Frail/Normal RASM subjects (1.0 (0.04) versus 0.84 (0.05) ng/ml/kg, P=0.01). Median (IQR) IGF-1 level was lower amongst Frail/Low RASM subjects compared to Frail/Normal RASM subjects (102.3, (77.7, 102.5) vs 119.7 (82.7, 146.0) ng/ml, P=0.046). No differences in myostatin or IGF-1 were observed among robust individuals with or without low muscle mass. In adjusted multinomial logistic regression models with Robust/Normal RASM as the reference group, myostatin (P=0.05) and IGF-1 (P=0.043) were associated with Frail/Low RASM status in the whole cohort. When stratified by gender, myostatin was significantly associated with Frail/Low RASM status in men only (P=0.03). In women, serum IGF-1 was associated with Frail/Low RASM status (P=0.046), but not myostatin (P=0.53).

CONCLUSION

Serum myostatin, normalized for TBLM in men and IGF-1 in women are potential biomarkers for frail individuals with low RASM, and may identify a target group for intervention.

Elevated serum IL-6 and adiponectin levels are associated with frailty and physical function in Chinese older adults

Purpose

Frailty is associated with adverse health outcomes. Its biological markers are essential to enhance diagnostic ease and would contribute to surveillance of the condition. Considering the involvement of pro-inflammatory and nutritional states in frailty, we aimed to investigate whether inflammatory mediators and adipokines are associated with frailty and their relationship with physical function.

Patients and methods

We recruited 130 older adults (90 nonfrail participants and 40 frail participants, mean age: 72.80±8.61 years) who underwent a comprehensive medical history and frailty assessment. The biochemical indicators (eg, blood urea nitrogen [BUN], high-density lipoprotein [HDL], and hemoglobin [HGB]), insulin pathway (glucose, insulin, and insulin-like growth factor 1 [IGF-1]), circulating inflammatory biomarkers (IL-6, tumor necrosis factor receptor 1, and C-reactive protein), and adipokines (adiponectin, vaspin, and leptin) were compared between the two groups. We further analyzed their correlation with physical function.

Results

Frail older adults showed higher levels of BUN, IL-6, adiponectin, vaspin, and glucose and lower levels of IGF-1, HDL, and HGB compared with nonfrail participants. Serum IL-6 levels were negatively correlated with both grip strength (P=0.03) and gait speed (P=0.04). Levels of circulating adiponectin and leptin were adversely correlated with grip strength (P=0.01) and gait speed (P=0.03), respectively. After adjustment for age and sex, the only markers correlated with physical function were IL-6 (r=−0.180, P=0.044) and adiponectin (r=−0.195, P=0.029).

Conclusion

High levels of IL-6, adiponectin, vaspin, and glucose as well as low levels of IGF-1 were found in frail older adults. Furthermore, IL-6, adiponectin, and leptin levels were negatively correlated with physical function, suggesting that inflammatory mediators and adipokines are biomarkers for frailty and decreased function in older adults.

Transitional status and modifiable risk of frailty in Japanese older adults: A prospective cohort study

AIM

The purpose of the present study was to identify risk factors for physical frailty and to understand the transitional status of frailty.

METHODS

The participants were 4676 older adults in the National Center for Geriatrics and Gerontology - Study of Geriatric Syndromes. Physical frailty status was classified as robust, pre-frail and frail at baseline and 4-year follow up (mean follow up 47.9 ± 1.8 months). Data for demographic variables, medical conditions, fall, depressive symptoms and cognitive function were also collected. Multiple imputation was used to reduce selection bias and loss of information.

RESULTS

Progression occurred from a robust to frail status in 52 participants (2.6%) and from pre-frailty to frailty in 281 participants (12.0%). Mortality increased with frailty status at baseline: robust 46 (2.3%), pre-frail 112 (4.8%) and frail 54 (15.6%). In logistic regression analysis, age (OR 1.10, 95% CI 1.06-1.13), sex (men; OR 0.67, 95% CI 0.46-0.95), body mass index (OR 1.06, 95% CI 1.01-1.12]), fall (OR 1.92, 95% CI 1.31-2.81), Geriatric Depression Scale (OR 1.15, 95% CI 1.08-1.22), Mini-Mental State Examination (OR 0.87, 95% CI 0.82-0.93) and education (OR 0.91, 95% CI 0.85-0.98), were related with new incident frailty. Among participants in the pre-frail class at baseline, exhaustion (OR 3.24, 95% CI 1.97-5.34), physical inactivity (OR 3.09, 95% CI 1.94-4.93), lower muscle strength (OR 3.77, 95% CI 2.35-6.03) and lower mobility (OR 2.54, 95% CI 1.57-4.10) were related to progression to frailty (all P < 0.05).

CONCLUSIONS

The results of the present prospective study provide key information on the transitional status of frailty and the risk factors for progression to frailty. A further study is required to determine the pathophysiological changes that underlie the transition to frailty. Geriatr Gerontol Int 2018; 18: 1562-1566.

Appetite, Metabolism and Hormonal Regulation in Normal Ageing and Dementia

Feeding and nutrition follow the growth trajectory of the course of life. The profound physiological changes that human body experiences during ageing affect separate aspects of food intake, from tastant perception to satiety. Concurrent morbidities, such as neurodegeneration, as seen in dementia, and metabolic syndrome, may further shape nutritional behaviours, status and adequacy. In an effort to fill the gap between the exhausting basic research and the actual needs of professionals caring for the exponentially expanding ageing population, the current review addresses major factors relevant to appetite and eating disturbances. Does age alter the perception of food modalities? Is food generally still perceived as alluring and delicious with age? Is there an interplay between ageing, cognitive decline, and malnutrition? What tools can we adopt for proper and timely monitoring? Finally, what anatomical and pathophysiological evidence exists to support a hypothesis of central regulation of metabolic perturbations in normal and accelerated cognitive impairment, and how can we benefit from it in health practice?