Screening for and Managing the Person with Frailty in Primary Care: ICFSR Consensus Guidelines

Global consensus on optimal exercise recommendations for enhancing healthy longevity in older adults (ICFSR)

Aging, a universal and inevitable process, is characterized by a progressive accumulation of physiological alterations and functional decline over time, leading to increased vulnerability to diseases and ultimately mortality as age advances. Lifestyle factors, notably physical activity (PA) and exercise, significantly modulate aging phenotypes. Physical activity and exercise can prevent or ameliorate lifestyle-related diseases, extend health span, enhance physical function, and reduce the burden of non-communicable chronic diseases including cardiometabolic disease, cancer, musculoskeletal and neurological conditions, and chronic respiratory diseases as well as premature mortality. Physical activity influences the cellular and molecular drivers of biological aging, slowing aging rates-a foundational aspect of geroscience. Thus, PA serves both as preventive medicine and therapeutic agent in pathological states. Sub-optimal PA levels correlate with increased disease prevalence in aging populations. Structured exercise prescriptions should therefore be customized and monitored like any other medical treatment, considering the dose-response relationships and specific adaptations necessary for intended outcomes. Current guidelines recommend a multifaceted exercise regimen that includes aerobic, resistance, balance, and flexibility training through structured and incidental (integrated lifestyle) activities. Tailored exercise programs have proven effective in helping older adults maintain their functional capacities, extending their health span, and enhancing their quality of life. Particularly important are anabolic exercises, such as Progressive resistance training (PRT), which are indispensable for maintaining or improving functional capacity in older adults, particularly those with frailty, sarcopenia or osteoporosis, or those hospitalized or in residential aged care. Multicomponent exercise interventions that include cognitive tasks significantly enhance the hallmarks of frailty (low body mass, strength, mobility, PA level, and energy) and cognitive function, thus preventing falls and optimizing functional capacity during aging. Importantly, PA/exercise displays dose-response characteristics and varies between individuals, necessitating personalized modalities tailored to specific medical conditions. Precision in exercise prescriptions remains a significant area of further research, given the global impact of aging and broad effects of PA. Economic analyses underscore the cost benefits of exercise programs, justifying broader integration into health care for older adults. However, despite these benefits, exercise is far from fully integrated into medical practice for older people. Many healthcare professionals, including geriatricians, need more training to incorporate exercise directly into patient care, whether in settings including hospitals, outpatient clinics, or residential care. Education about the use of exercise as isolated or adjunctive treatment for geriatric syndromes and chronic diseases would do much to ease the problems of polypharmacy and widespread prescription of potentially inappropriate medications. This intersection of prescriptive practices and PA/exercise offers a promising approach to enhance the well-being of older adults. An integrated strategy that combines exercise prescriptions with pharmacotherapy would optimize the vitality and functional independence of older people whilst minimizing adverse drug reactions. This consensus provides the rationale for the integration of PA into health promotion, disease prevention, and management strategies for older adults. Guidelines are included for specific modalities and dosages of exercise with proven efficacy in randomized controlled trials. Descriptions of the beneficial physiological changes, attenuation of aging phenotypes, and role of exercise in chronic disease and disability management in older adults are provided. The use of exercise in cardiometabolic disease, cancer, musculoskeletal conditions, frailty, sarcopenia, and neuropsychological health is emphasized. Recommendations to bridge existing knowledge and implementation gaps and fully integrate PA into the mainstream of geriatric care are provided. Particular attention is paid to the need for personalized medicine as it applies to exercise and geroscience, given the inter-individual variability in adaptation to exercise demonstrated in older adult cohorts. Overall, this consensus provides a foundation for applying and extending the current knowledge base of exercise as medicine for an aging population to optimize health span and quality of life.

Ketoanalogue use is associated with a lower risk of worsening frailty among patients with diabetic kidney disease of advanced stage: A retrospective cohort study

Background

Patients with diabetes kidney disease (DKD) are at risk of developing frailty, leading to functional impairment and poor outcomes. Medications are potential modifiers of such risk. Ketoanalogues have been shown to delay dialysis initiation in DKD patients. We investigated whether ketoanalogues use influenced the risk of worsening frailty in this population.

Methods

From 840,000 patients with diabetes, we identified those with DKD but without full-fledged frailty, and divided them into those with and without receiving ketoanalogue, followed by propensity score matching in 1:4 ratio. Worsening frailty was defined as ≥1 positive FRAIL item increase compared to baseline status (0, 1, or 2 items) during follow-up. We used Cox proportional hazard regression to estimate the probability of worsening frailty, adjusting for demographics, comorbidities, glycemic control, renal function, treatments and medications.

Results

Totally 183 and 732 ketoanalogue users and matched non-users were identified, respectively. The mean age of included patients was 57.4 years, with 91.3 % having non-dialysis stage 5 chronic kidney disease. Approximately two-thirds had pre-frailty (1 o2 items). After 3.72 years, 16.6 % patients had worsening frailty. Multivariate analyses, adjusting for confounders disclosed that ketoanalogue users (≥14 days) had a significantly lower risk of worsening frailty than non-users (hazard ratio (HR) 0.52, 95 % confidence interval (CI) 0.32-0.87). Sensitivity analysis including those received ketoanalogue ≥28 days showed even greater benefits (HR 0.45, 95 % CI 0.26-0.78).

Conclusions

Patients with DKD receiving ketoanalogues were less likely to have worsening frailty over time than non-users. Our findings uncover a new potential strategy of ameliorating frailty progression in this population carrying a high risk of accelerated aging.

Frailty Screening in Primary Care-Based Memory Clinics: Feasibility, Acceptability, and Preliminary Findings

We evaluated the feasibility and acceptability of frailty screening using handgrip strength with gait speed measures within four primary care-based memory clinics in Ontario. This mixed methods quality improvement initiative examined the reach, effectiveness, adoption, implementation, and maintenance of frailty screening from the perspective of patients (N = 216), care partners (N = 142), and healthcare providers (N = 9). Frailty screening was well-received by patients and care partners and perceived as quick and easy to administer and integrate into assessment processes by healthcare providers at all four memory clinics. The ease of integrating frailty screening into clinic processes was a key factor facilitating implementation; few challenges or suggestions for improvement were identified. All four clinics plan to continue frailty screening, three using the methods adopted in this study. Integrating frailty screening into memory assessments is feasible and acceptable and, given the interactional relationship between frailty and dementia, provides a significant opportunity to improve health outcomes for older adults.

Frailty and malnutrition as predictors of major complications following posterior thoracolumbar fusion in elderly patients: a retrospective cohort study

BACKGROUND CONTEXT

The number of elderly patients with degenerative spinal deformity (DSD) is increasing, and posterior thoracolumbar fusion surgery is an effective treatment option, but there are often postoperative major complications, which may hinder the benefit for elderly patients. Currently, there is no consensus on the best risk assessment technique for predicting major complications in elderly patients undergoing long-segment fusion surgery.

PURPOSE

This study constructs a risk assessment model using the Modified 5-Item Frailty Index (mFI-5) and serum albumin and evaluates its predictive value.

STUDY DESIGN

This is a retrospective analysis of a prospectively established database of DSD.

PATIENT SAMPLE

Consecutive patients (aged 65 and older) who underwent open posterior thoracolumbar fusion surgery for DSD between April 2018 and December 2023 were included.

OUTCOME MEASURES

Outcome measures included postoperative major complications, length of hospital stay [LOS], readmission and reoperation within 30 days, discharge disposition, physiological function recovery.

METHODS

The study reviewed consecutive patients who underwent open posterior thoracolumbar fusion surgery for DSD. Patients were divided into three groups based on the presence or absence of frailty or frailty combined with malnutrition. Spearman ρ analysis was used to assess the correlation between mFI-5 and serum albumin levels. Univariate analyses and multivariate logistic regression were conducted to explore the relationship between frailty and malnutrition defined by mFI-5 and serum albumin and major postoperative complications. Finally, the Receiver Operating Characteristic (ROC) curve was used to evaluate the predictive value of this model for major complications.

RESULTS

Compared to the Normal group (n=59), both the Frailty group (n=121) and the Frailty and Malnutrition group (n=50) had higher rates of major complications (21.5% vs. 8.5%, p=.035; 28% vs. 8.5%, p=.002). Multivariate logistic regression showed that frailty and malnutrition status, higher ASA score, and more bleeding were independent predictors of major postoperative complications. The ROC curve demonstrated that frailty combined with malnutrition defined by mFI-5 and serum albumin had a larger area under the curve compared to mFI-5 or serum albumin alone (AUC: 0.676; 95% CI: 1.101-14.129; p<.001).

CONCLUSIONS

Compared to considering frailty or malnutrition alone, the combined assessment of frailty and malnutrition using mFI-5 and serum albumin is valuable in predicting major complications in elderly patients undergoing posterior thoracolumbar fusion surgery.

[PAPPS update on older people 2024]

Population aging is a global phenomenon that is increasing the proportion of older people, particularly those over 80 years old. This increase in longevity does not always translate into years of good quality of life. This document reviews the latest evidence on the main preventive activities for older adults, starting with major geriatric syndromes such as frailty, cognitive impairment, and social isolation. It evaluates direct interventions in nutrition, deprescription, and physical exercise. Additionally, for the first time, it includes an analysis of preventive activities related to suicide in older adults, coordinated with mental health promotion programs. Frailty, defined as the progressive deterioration of physiological systems, is a significant predictor of adverse health events and is considered potentially reversible, especially in its early stages. The diagnosis and management of frailty through comprehensive geriatric assessment (CGA) and the implementation of specific interventions such as multicomponent exercise, adequate nutrition, and medication review are key to improving the functionality and quality of life of older adults.

Effectiveness of community-based Baduanjin exercise intervention for older adults with varying frailty status: a randomized controlled trial

BACKGROUND

Due to poorer exercise tolerance, it may be challenging for frail older adults to engage in moderate- or vigorous-intensity exercise. While low-intensity exercise interventions may be more feasible, its effectiveness for such population group remains unclear. We examined the effectiveness and implementation of community-based Baduanjin Qigong, a low-intensity exercise program in older adults with varying frailty status.

METHODS

A two-arm, multicenter assessor-blind parallel group randomized controlled trial was conducted at three local senior activity centers. Fifty-six community-dwelling older adults with low handgrip strength were randomly allocated to either the intervention (IG) or wait-list control (CG) group. The IG underwent a supervised 16-week Baduanjin exercise program at a frequency of 2-3 × 60 min sessions/week. The CG was instructed to maintain their usual activity and received a monthly health education talk. The primary outcome measures were knee extension strength, vital exhaustion, and fear of falling. Secondary outcome measures include physiological falls risk, handgrip strength, gait speed, timed up and go test, 30-second sit-to-stand, quality of life, depression, and frailty. All outcome measures were assessed at baseline and 4-month follow-up.

RESULTS

Overall, there were no statistically significant differences in all outcome measures between CG and IG at 4-month follow-up. However, in exploratory compliance analysis, a statistically significant group x time interaction was found for vital exhaustion (B = -3.65, 95% CI [-7.13, -0.16], p = .047) among participants with at least 75% attendance. In post-hoc within-group comparisons, IG showed improved vital exhaustion by 4.31 points (95% CI [1.41, 7.20], d = 0.60). The average participant attendance rate was 81.3%. No major adverse events occurred, and all participants reported positive experiences with the exercise intervention.

CONCLUSIONS

Our study demonstrated that Baduanjin is a safe, feasible, and acceptable exercise program that can be successfully implemented in community settings for older adults with varying frailty status. With good adherence, Baduanjin exercise could potentially be effective in alleviating vital exhaustion. However, the effectiveness of Baduanjin on physical performance, psychological measures and frailty in community-dwelling older adults remains equivocal.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04549103. Registered September 16, 2020.

Development and validation of a diagnostic nomogram for frailty in cancer patients

BACKGROUND

The presence of frailty decreases the overall survival of cancer patients. An accurate and operational diagnostic method is needed to help clinicians choose the most appropriate treatment to improve patient outcomes.

METHODS

Data were collected from 10 649 cancer patients who were prospectively enrolled in the Investigation on Nutritional Status and its Clinical Outcomes of Common Cancers (INSCOC) project in China from July 2013 to August 2022. The training cohort and validation cohort were randomly divided at a ratio of 7:3. The multivariable logistic regression analysis, multivariate Cox regression analyses, and the least absolute shrinkage and selection operator (LASSO) method were used to develop the nomogram. The concordance index and calibration curve were used to assess the diagnostic utility of the nomogram model.

RESULTS

The 10 risk factors associated with frailty in cancer patients were age, AJCC stage, liver cancer, hemoglobin, radiotherapy, surgery, hand grip strength (HGS), calf circumference (CC), PG-SGA score and QOL from the QLQ-C30. The diagnostic nomogram model achieved a good C index of 0.847 (95% CI, 0.832-0.862, P < 0.001) in the training cohort and 0.853 (95% CI, 0.83-0.876, P < 0.001) in the validation cohort. The prediction nomogram showed 1-, 3-, and 5-year mortality C indices in the training cohort of 0.708 (95% CI, 0.686-0.731), 0.655 (95% CI, 0.627-0.683), and 0.623 (95% CI, 0.568-0.678). The 1-, 3-, and 5-year C indices in the validation cohort were similarly 0.743 (95% CI, 0.711-0.777), 0.680 (95% CI, 0.639-0.722), and 0.629 (95% CI, 0.558-0.700). In addition, the calibration curves and decision curve analysis (DCA) were well-fitted for both the diagnostic model and prediction model.

CONCLUSIONS

The nomogram model provides an accurate method to diagnose frailty in cancer patients. Using this model could lead to the selection of more appropriate therapy and a better prognosis for cancer patients.

Determining the minimum data set of geriatric assessment at the Iran primary health care referral system: shifting from fragmentation to integration care for older people

BACKGROUND

Geriatric assessment (GA) is a multidimensional process that disrupts the primary health care (PHC) referral system. Accessing consistent data is central to the provision of integrated geriatric care across multiple healthcare settings. However, due to poor-quality data and documentation of GA, developing an agreed minimum data set (MDS) is required. Therefore, this study aimed to develop a GA-MDS in the PHC referral system to improve data quality, data exchange, and continuum of care to address the multifaceted necessities of older people.

METHODS

In our study, the items to be included within GA-MDS were determined in a three-stepwise process. First, an exploratory literature search was done to determine the related items. Then, we used a two-round Delphi survey to obtain an agreement view on items to be contained within GA-MDS. Finally, the validity of the GA-MDS content was evaluated.

RESULTS

Sixty specialists from different health geriatric care disciplines scored data items. After, the Delphi phase from the 230 selected items, 35 items were removed by calculating the content validity index (CVI), content validity ratio (CVR), and other statistical measures. Finally, GA-MDS was prepared with 195 items and four sections including administrative data, clinical, physiological, and psychological assessments.

CONCLUSIONS

The development of GA-MDS can serve as a platform to inform the geriatric referral system, standardize the GA process, and streamline their referral to specialized levels of care. We hope GA-MDS supports clinicians, researchers, and policymakers by providing aggregated data to inform medical practice and enhance patient-centered outcomes.

The conveyor belt for older people nearing the end of life

The current fallback position for the elderly frail nearing the end of life (less than 12 months to live) is hospitalisation. There is a reluctance to use the term 'terminally ill' for this population, resulting in overtreatment, overdiagnosis and management that is not consistent with the wishes of people. This is the major contributor to the so-called hospital crisis, including decreased capacity of hospitals, reduced ability to conduct elective surgery, increased attendances at emergency departments and ambulance ramping. The authors recently conducted the largest randomised study, to their knowledge, attempting to inform specialist hospital medical teams about the terminally ill status of their admitted patients. This information did not influence their clinical decisions in any way. The authors discuss the reasons why this may have occurred, such as the current avoidance of discussing death and dying by society and the concentration of healthcare workers on actively managing the acute presenting problem and ignoring the underlying prognosis in the elderly frail. The authors discuss ways of improving the management of the elderly nearing the end of life, such as more detailed goals of care discussions using the concept of shared decision-making rather than simply completing Advanced Care Decision documents. Empowering people in this way could become the most important driver of people's health care.

Diabetic Sarcopenia. A proposed muscle screening protocol in people with diabetes : Expert document

OBJECTIVES

To propose the grounds for "diabetic sarcopenia" as a new comorbidity of diabetes, and to establish a muscle screening algorithm proposal to facilitate its diagnosis and staging in clinical practice.

METHOD

A qualitative expert opinion study was carried out using the nominal technique. A literature search was performed with the terms "screening" or "diagnostic criteria" and "muscle loss" or "sarcopenia" and "diabetes" that was sent to a multidisciplinary group of 7 experts who, in a face-to-face meeting, discussed various aspects of the screening algorithm.

RESULTS

The hallmark of diabetic sarcopenia (DS) is muscle mass atrophy characteristic of people with diabetes mellitus (DM) in contrast to the histological and physiological normality of muscle mass. The target population to be screened was defined as patients with DM with a SARC-F questionnaire > 4, glycosylated haemoglobin (HbA1C) ≥ 8.0%, more than 5 years since onset of DM, taking sulfonylureas, glinides and sodium/glucose cotransporter inhibitors (SGLT2), as well as presence of chronic complications of diabetes or clinical suspicion of sarcopenia. Diagnosis was based on the presence of criteria of low muscle strength (probable sarcopenia) and low muscle mass (confirmed sarcopenia) using methods available in any clinical consultation room, such as dynamometry, the chair stand test, and Body Mass Index (BMI)-adjusted calf circumference. DS was classified into 4 stages: Stage I corresponds to sarcopenic patients with no other diabetes complication, and Stage II corresponds to patients with some type of involvement. Within Stage II are three sublevels (a, b and c). Stage IIa refers to individuals with sarcopenic diabetes and some diabetes-specific impairment, IIb to sarcopenia with functional impairment, and IIc to sarcopenia with diabetes complications and changes in function measured using standard tests Conclusion: Diabetic sarcopenia has a significant impact on function and quality of life in people with type 2 diabetes mellitus (T2DM), and it is important to give it the same attention as all other traditionally described complications of T2DM. This document aims to establish the foundation for protocolising the screening and diagnosis of diabetic sarcopenia in a manner that is simple and accessible for all levels of healthcare.

A Modified Frailty Phenotype Used for Identifying Frailty in Health Care Practice: Validation Among Chinese Older Adults

OBJECTIVES

The study aimed to evaluate a simplified and practical frailty detection tool derived from the Fried frailty phenotype (FFP). This tool was developed to facilitate the identification of frail individuals in constrained settings, addressing the challenges posed by uncertain cutoffs of FFP indicators in prompt frailty assessment.

DESIGN

A longitudinal study and a cross-sectional study.

SETTINGS AND PARTICIPANTS

A total of 1978 older adults aged 67.4 ± 6.16 years from the China Health and Retirement Longitudinal Study (CHARLS), and 972 older adults aged 72.8 ± 6.75 years from a pilot cross-sectional study conducted in Shanghai communities.

METHODS

Frailty was assessed according to the FFP criterion. A Chinese modified frailty phenotype (CMFP) was developed, incorporating specific cutoffs for grip strength and an alternative test for walk speed. The internal consistency reliability, the criterion, and predictive validity of the CMFP were evaluated.

RESULTS

The 5-time chair stand test (5t-CST) was significantly associated with the 2.5-m walk test (r = 0.373 in the CHARLS and 0.423 in the pilot study). Each element of the CMFP showed moderate to strong correlations with the total CMFP score and showed Cronbach's alpha of 0.303 and 0.358 in both populations. The Spearman's r and kappa values between the CMFP and the FFP were 0.795 and 0.663 in the CHARLS, and 0.676 and 0.537 in the pilot study. The areas under the curve (AUC) were 0.936 and 0.928 in the 2 studies, respectively. In addition, frailty assessed by the CMFP significantly predicted future incidence of outcomes, including all-cause mortality, activities of daily living (ADL)/instrumental ADL disability, hospitalization, and depression.

CONCLUSIONS AND IMPLICATIONS

The study demonstrated the CMFP as a valid tool, particularly highlighting its excellent predictive ability on outcomes. The 5t-CST may act as a viable alternative test for assessing slowness. The CMFP can be systematically integrated into preclinical practice to identify frail individuals, especially within constrained spaces.

Hospital-Based Health Professionals' Perceptions of Frailty in Older People

BACKGROUND AND OBJECTIVES

There is a high prevalence of frailty amongst older patients in hospital settings. Frailty guidelines exist but implementation to date has been challenging. Understanding health professional attitudes, knowledge, and beliefs about frailty is critical in understanding barriers and enablers to guideline implementation, and the aim of this study was to understand these in rehabilitation multidisciplinary teams in hospital settings.

RESEARCH DESIGN AND METHODS

Twenty-three semistructured interviews were conducted with health professionals working in multidisciplinary teams on geriatric and rehabilitation wards in Adelaide and Sydney, Australia. Interviews were audio recorded, transcribed, and coded by 2 researchers. A codebook was created and interviews were recoded and applied to the Framework Method of thematic analysis.

RESULTS

Three domains were developed: diagnosing frailty, communicating about frailty, and managing frailty. Within these domains, 8 themes were identified: (1) diagnosing frailty has questionable benefits, (2) clinicians don't use frailty screening tools, (3) frailty can be diagnosed on appearance and history, (4) frailty has a stigma, (5) clinicians don't use the word "frail" with patients, (6) frailty isn't always reversible, (7) there is a lack of continuity of care after acute admission, and (8) the community setting lacks resources.

DISCUSSION AND IMPLICATIONS

Implementation of frailty guidelines will remain challenging while staff avoid using the term "frail," don't perceive benefit of using screening tools, and focus on the individual aspects of frailty rather than the syndrome holistically. Clinical champions and education about frailty identification, reversibility, management, and communication techniques may improve the implementation of frailty guidelines in hospitals.

Sarcopenia Prevalence and Risk Factors Among Older Adults in Bangkok, Thailand: A Cross-Sectional Study

OBJECTIVES

This study aimed to investigate the prevalence of sarcopenia among older Thai adults residing in Bangkok and identify associated risk factors.

METHODS

This cross-sectional study included Thai adults aged ≥60 years. All participants underwent assessments using the Yubi-wakka test, anthropometric measurements, bioelectrical impedance analysis, handgrip strength tests, and physical performance evaluations. Information on demographic characteristics, chronic health conditions, nutritional status, and medication use was also collected. Sarcopenia was diagnosed according to the 2019 Asian Working Group for Sarcopenia criteria. Statistical analyses were performed using the independent t-test, Chi-square test, and logistic regression to identify risk factors.

RESULTS

Among the 600 participants, the overall prevalence of sarcopenia was 19%. The multivariate analysis identified 13 significant risk factors associated with sarcopenia, including age ≥75 years (odds ratio [OR]=10.6, 95% confidence interval [CI]=3.7-30.2), higher education level (year) (OR=0.85, 95% CI=0.74-0.98), lower income level (OR=5.4, 95% CI=1.4-21.4), Barthel index <90 (OR=11.0, 95% CI=3.5-34.5), lower body mass index (OR=0.7, 95% CI=0.6-0.8), low calf circumference (OR=7.6, 95% CI=2.5-23.3), fall in the past year (OR, 3.1; 95% CI, 1.4-6.6), frailty (OR, 2.3; 95% CI, 1.1-4.5), malnutrition (OR=3.5, 95% CI=1.3-9.3), history of stroke (OR=7.5, 95% CI=1.3-41.4), vitamin D deficiency (OR=9.4, 95% CI=1.1-82.5), knee osteoarthritis (OR=6.3, 95% CI=1.57-25.31), and malignancy (OR=4.8, 95% CI=1.01-22.70).

CONCLUSION

This study evaluated the sarcopenia status across a diverse demographic of older Thai adults using comprehensive assessments, and examined the impact of socioeconomic factors and various chronic conditions on the occurrence of sarcopenia.

Association between different skeletal muscle mass indices, physical function, and inflammation in obese pre-frail older adults

OBJECTIVES

There is lack of consensus on measurement of muscle mass and quality in obese older adults. We aim to evaluate the association of four muscle mass indices (appendicular skeletal muscle mass (ASM) over height2(ASMIht), ASM/weight (ASMwt), ASM/body fat percentage (ASMbfp)and ASM/body mass index (BMI) ASMIbmi) with physical function and inflammation in pre-frail obese older adults.

METHODS

Cross-sectional study of 407 community dwelling pre-frail older adults. Data on demographics, cognition, and physical function(gait speed, handgrip strength (HGS) and Short Physical Performance Battery (SPPB) test), body composition and inflammation biomarkers were collected. Participants were analysed based on BMI tertiles(T1 lowest,T3 highest).

RESULTS

The mean age was 72.67 years, mean BMI 25.42 kg/m2 and 59.5 % were females. Participants in T3 had a mean BMI of 30.75 kg/m2, younger with lower education levels, multimorbidity, polypharmacy and lower prevalence of sarcopenia. In BMI T3, ASMIbmi was significantly associated with EQ-5D index (β 0.53, 95 % CI 0.04 to 1.03, p = 0.033),HGS (β 5.28, 95 % CI 0.27 to 10.29, p = 0.039), SPPB (β 2.19, 95 % CI 0.47 to 3.91, p = 0.013) and IL-6 (β -4.13, 95 % CI -7.46 to -0.81, p = 0.017). ASMIwt was associated with EQ-5D index (β 0.17, 95 % CI 0.02 - 0.33, p = 0.047). ASMbfp was associated with HGS (β 6.97, 95 % CI 0.051 to 13.92, p = 0.049). There was significant association of HGS with all muscle mass indices in BMI T2, and ASMbfpin BMI T1.

CONCLUSION

ASMIbmi was significantly associated with SPPB, HGS, EQ-5D index and IL-6 in BMI T3. ASMbfp was associated with HGS in all the tertiles. Our results need further validation at population level.

Association of CT-Derived Skeletal Muscle and Adipose Tissue Metrics with Frailty in Older Adults

RATIONALE AND OBJECTIVES

Tools are needed for frailty screening of older adults. Opportunistic analysis of body composition could play a role. We aim to determine whether computed tomography (CT)-derived measurements of muscle and adipose tissue are associated with frailty.

MATERIALS AND METHODS

Outpatients aged ≥ 55 years consecutively imaged with contrast-enhanced abdominopelvic CT over a 3-month interval were included. Frailty was determined from the electronic health record using a previously validated electronic frailty index (eFI). CT images at the level of the L3 vertebra were automatically segmented to derive muscle metrics (skeletal muscle area [SMA], skeletal muscle density [SMD], intermuscular adipose tissue [IMAT]) and adipose tissue metrics (visceral adipose tissue [VAT], subcutaneous adipose tissue [SAT]). Distributions of demographic and CT-derived variables were compared between sexes. Sex-specific associations of muscle and adipose tissue metrics with eFI were characterized by linear regressions adjusted for age, race, ethnicity, duration between imaging and eFI measurements, and imaging parameters.

RESULTS

The cohort comprised 886 patients (449 women, 437 men, mean age 67.9 years), of whom 382 (43%) met the criteria for pre-frailty (ie, 0.10 < eFI ≤ 0.21) and 138 (16%) for frailty (eFI > 0.21). In men, 1 standard deviation changes in SMD (β = -0.01, 95% confidence interval [CI], -0.02 to -0.001, P = .02) and VAT area (β = 0.008, 95% CI, 0.0005-0.02, P = .04), but not SMA, IMAT, or SAT, were associated with higher frailty. In women, none of the CT-derived muscle or adipose tissue metrics were associated with frailty.

CONCLUSION

We observed a positive association between frailty and CT-derived biomarkers of myosteatosis and visceral adiposity in a sex-dependent manner.

Summary of best evidence for prevention and management of frailty

BACKGROUND

Frailty in older people can seriously affect their quality of life and increase the demand for long-term care and health care expenses. Aims of this study are to provide an evidence-based basis for clinical practice of frailty in older people by systematically searching for the best current evidence on interventions for the prevention and management of frailty.

METHODS

According to the '6S' evidence resource model, evidence retrieval is searched from the top-down and collected relevant guidelines, best practices, evidence summaries, systematic reviews and expert consensus. The retrieval time limit was from the database establishment to 20 March 2023. Two reviewers independently screened and evaluated the literature, and then extracted and summarised the evidence according to the JBI grading of evidence and recommendation system.

RESULTS

A total of 44 publications were finally included, including 12 guidelines, 5 best practices, 4 expert consensus, 5 evidence summaries and 18 systematic reviews. Through the induction and integration of the evidence, the evidence was finally summarised from eight aspects: frailty screening, frailty assessment, exercise intervention, nutrition intervention, multi-domain intervention, drug administration, social support and health education, and 43 best evidences were formed.

CONCLUSIONS

This study summarised the best evidence for the prevention and management of frailty from eight aspects, which can provide guidance for clinical or community medical staff to develop and apply frailty intervention and practice programmes for older people and improved the clinical outcome and quality of life of older people.

New horizons in frailty identification via electronic frailty indices: early implementation lessons from experiences in England and the United States

Frailty represents an integrative prognostic marker of risk that associates with a myriad of age-related adverse outcomes in older adults. As a concept, frailty can help to target scarce resources and identify subgroups of vulnerable older adults that may benefit from interventions or changes in medical management, such as pursing less aggressive glycaemic targets for frail older adults with diabetes. In practice, however, there are several operational challenges to implementing frailty screening outside the confines of geriatric medicine. Electronic frailty indices (eFIs) based on the theory of deficit accumulation, derived from routine data housed in the electronic health record, have emerged as a rapid, feasible and valid approach to screen for frailty at scale. The goal of this paper is to describe the early experience of three diverse groups in developing, implementing and adopting eFIs (The English National Health Service, US Department of Veterans Affairs and Atrium Health-Wake Forest Baptist). These groups span different countries and organisational complexity, using eFIs for both research and clinical care, and represent different levels of progress with clinical implementation. Using an implementation science framework, we describe common elements of successful implementation in these settings and set an agenda for future research and expansion of eFI-informed initiatives.

Facilitators and barriers to the implementation of dietary nutrition interventions for community-dwelling older adults with physical frailty and sarcopenia: A qualitative meta-synthesis

Objectives

With the acceleration of an aging society, the prevalence of age-related chronic diseases such as physical frailty and sarcopenia is gradually increasing with numerous adverse effects. Dietary nutrition is an important modifiable risk factor for the management of physical frailty and sarcopenia, but there are many complex influences on its implementation in community settings. This study aimed to summarize the facilitators and barriers to the implementation of dietary nutrition interventions for community-dwelling older adults with physical frailty and sarcopenia, and to provide a reference for the formulation of relevant health management programs.

Methods

Searches were conducted in databases including PubMed, Web of Science, Medline (Ovid), Embase (Ovid), and Cochrane Library from inception to January 2023. Searches were completed for a combination of MeSH terms and free terms. The Critical Appraisal Skills Program (CASP) instrument was used to appraise quality. Coding and analysis of the extracted information were performed using the socio-ecological modeling framework. The study protocol for this review was registered on the PROSPERO ( CRD42022381339).

Results

A total of 10 studies were included. Of these, four were nutrition-only focused interventions, and six were dietary nutrition and exercise interventions. The facilitators and barriers were summarized based on the socio-ecological model that emerged at three levels: individual trait level, external environment level, and intervention-related level, containing ten subthemes.

Conclusion

Individual internal motivation and external support should be integrated with the implementation of diet- and nutrition-related interventions in community-living aged people with physical frailty and sarcopenia. Develop "tailored" interventions for participants and maximize available human and physical resources.

Frailty prevalence and efficient screening in primary care-based memory clinics

BACKGROUND

Little is known about the prevalence of frailty among patients with memory concerns attending a primary care-based memory clinic.

OBJECTIVE

This study aims to describe the prevalence of frailty among patients attending a primary care-based memory clinic and to determine if prevalence rates differ based on the screening tool that is used.

METHODS

We conducted a retrospective medical record review for all consecutive patients assessed in a primary care-based memory clinic over 8 months. Frailty was measured in 258 patients using the Fried frailty criteria, which relies on physical measures, and the Clinical Frailty Scale (CFS), which relies on functional status. Weighted kappa statistics were calculated to compare the Fried frailty and the CFS.

RESULTS

The prevalence of frailty was 16% by Fried criteria and 48% by the CFS. Agreement between Fried frailty and CFS was fair for CFS 5+ (kappa = 0.22; 95% confidence interval: 0.13, 0.32) and moderate for CFS 6+ (kappa = 0.47; 0.34, 0.61). Dual-trait measures of hand grip strength with gait speed were found to be a valid proxy for Fried frailty phenotype.

CONCLUSIONS

Among primary care patients with memory concerns, frailty prevalence rates differed based on the measure used. Screening for frailty in this population using measures relying on physical performance may be a more efficient approach for persons already at risk of further health instability from cognitive impairment. Our findings demonstrate how measure selection should be based on the objectives and context in which frailty screening occurs.

Frailty and sarcopenia: A bibliometric analysis of their association and potential targets for intervention

Frailty and sarcopenia are age-related diseases, and exhibit a concomitant relationship, as they share many common clinical features and etiological factors. Transitions within frailty status would be influenced by the presence of sarcopenia. Investigating their association to devise efficacious intervention and management strategies for geriatric patients is imperative, given their potentially unfavorable outcomes. In this study, the literature on sarcopenia and frailty was screened in the Web of Science core collection database over the past 30 years to ascertain the link between them through bibliometric analysis and the exploration of disease-related molecular pathways within the GeneCards and OMIM databases was conducted. Per inclusion and exclusion criteria, 3889 literature sources were selected for subsequent analysis. Keywords, including "cirrhosis" and "postoperative complications," represent the current and potential future research trends and focal points in this field. Moreover, 63 common potential targets between the two diseases were identified. Their pathogenesis involved cellular aging and endocrine metabolism regulation pathways, including AMPK, cell senescence, and the endocrine resistance pathway. This study identified an intimate correlation between frailty and sarcopenia in pathogenesis, prevention, and treatment measures, establishing a foundation for exploring shared prevention and treatment strategies for these two disorders.

Frailty syndrome in women with osteoporosis, should physicians consider screening? A cross-sectional study

Despite its high prevalence and profound impact, frailty syndrome often goes undiagnosed. The study revealed a significant correlation between osteoporosis and frailty syndrome, with predictive accuracy exceeding 75 %. Given these findings and the existing recommendation for osteoporosis screening in older women, we underscore the importance of concurrently screening osteoporotic women for frailty.

Introduction

Frailty syndrome, a prevalent and significant geriatric condition, impacts healthcare costs and quality of life. Previous reviews have associated frailty syndrome with osteoporosis, but original research on this link is limited and has produced conflicting results. This study aims to investigate the relationship between frailty syndrome, osteoporosis, bone mineral densitometry T-score, and other influencing factors.

Methods

In this cross-sectional study, post-menopausal women underwent screening for osteoporosis and frailty syndrome using bone mineral densitometry and the Fried phenotype. Exclusion criteria included a history of diseases related to bone loss or medications affecting bone metabolism. Bivariate and multivariable tests were used to examine the correlation between frailty syndrome and various covariates, including the diagnosis of osteoporosis.

Results

A total of 272 women aged 60 to 89 years (mean age 68.57 ± 6.22) were evaluated. Osteoporosis was prevalent in 44.9 % of participants, and frailty syndrome was identified in 36.4 %. The regression model identified age, menopausal age, and the diagnosis of osteoporosis as variables significantly and independently associated with frailty syndrome. A T-score lower than -2.5 in the femur neck or lumbar spine exhibited a sensitivity of 86.6 % and specificity of 76.5 % in predicting frailty syndrome.

Conclusion

Older adults with osteoporosis face an increased risk of frailty syndrome. Therefore, we recommend that primary care providers screen osteoporotic women for frailty syndrome and, when appropriate, refer this group to geriatric specialists for further evaluation.

Development and validation of a nomogram-assisted tool to predict potentially reversible cognitive frailty in Chinese community-living older adults

BACKGROUND

Cognitive frailty (CF) is a complex and heterogeneous clinical syndrome that indicates the onset of neurodegenerative processes and poor prognosis. In order to prevent the occurrence and development of CF in real world, we intended to develop and validate a simple and timely diagnostic instrument based on comprehensive geriatric assessment that will identify patients with potentially reversible CF (PRCF).

METHODS

750 community-dwelling individuals aged over 60 years were randomly allocated to either a training or validation set at a 4:1 ratio. We used the operator regression model offering the least absolute data dimension shrinkage and feature selection among candidate predictors. PRCF was defined as the presence of physical pre-frailty, frailty, and mild cognitive impairment (MCI) occurring simultaneously. Multivariate logistic regression was conducted to build a diagnostic tool to present data as a nomogram. The performance of the tool was assessed with respect to its calibration, discrimination, and clinical usefulness.

RESULTS

PRCF was observed in 326 patients (43%). Predictors in the tool were educational background, coronary heart disease, handgrip strength, gait speed, instrumental activity of daily living (IADL) disability, subjective cognitive decline (SCD) and five-times-sit-to-stand test. The diagnostic nomogram-assisted tool exhibited good calibration and discrimination with a C-index of 0.805 and a higher C-index of 0.845 in internal validation. The calibration plots demonstrated strong agreement in both the training and validation sets, while decision curve analysis confirmed the nomogram's efficacy in clinical practice.

CONCLUSIONS

This tool can effectively identify older adults at high risk for PRCF, enabling physicians to make informed clinical decisions and implement proper patient-centered individual interventions.

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

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

Healthy aging, early screening, and interventions for frailty in the elderly

With the intensification of population aging worldwide, the health problems of the elderly have become a particular concern. Functional disability is a prominent problem in the aging of this population, resulting in the decreased quality of life of senile people. Risk factors for functional disability in the elderly include geriatric syndromes and the associated diseases such as frailty. The influence of frailty on the health of the elderly has been a hot topic in recent years. As a dynamic and reversible geriatric syndrome, it has become one of the important public health problems emerging around the world. Frailty lies between self-reliance and the need for care and is reversible. Reasonable preventive interventions can restore the elderly to an independent life. If no interventions are implemented, the elderly will face a dilemma. There is no gold standard for frailty screening around the world. In order to alleviate frailty in the elderly, many countries have conducted early screening for frailty, mainly focusing on nutrition, physical activity, and social participation, in order to detect and prevent frailty earlier and to reduce the incidence of frailty. This topic provides an overview of the current status of frailty, early screening for frailty, and the interventions for frailty in most countries of the world.

Demographic and cardiovascular risk factors associated with pre-frailty and frailty among community-dwelling older adults in Jakarta, Indonesia: Active Aging Study

Introduction

This study aimed to evaluate the prevalence of frailty and its determinants, especially in relation to chronic disease and lifestyle among elderly individuals.

Method

A cross-sectional study was conducted among 278 individuals aged 60 years and over living in Jakarta. All participants underwent assessment, including medical history-taking, physical examination and blood tests for the sugar level and lipid profile. Frailty was assessed using the Frailty Instrument for Primary Care of the Survey of Health, Ageing and Retirement in Europe. All data were analysed using the chi-square test and multinomial logistic regression analysis.

Results

The prevalence of pre-frailty and frailty among the older adults was 40.6% and 28.8%, respectively. Female sex, lack of exercise, presence of cardiovascular diseases and high low-density lipoprotein cholesterol (LDL-C) level were associated with pre-frailty and frailty. Education for <9 years was associated only with frailty. After adjustments for all covariates, female sex (adjusted odds ratio [AOR] = 1.96, 95% confidence interval [CI]=1.07-3.60; AOR=3.93, 95% CI=1.87-8.24), lack of exercise (AOR=l4.81, 95% CI=5.07-43.26; AOR=49.48, 95% CI=16.20-151.09) and presence of cardiovascular diseases (AOR=5.32, 95% CI= 1.40-19.20; AOR=6.06, 95% CI= 1.63-22.56) were associated with pre-frailty and frailty. Meanwhile, education for <9 years (AO R= 1.97, 95% CI=1.05-3.69) and high LDL-C level (AOR=3.52, 95% CI=1.14-10.88) were associated with frailty.

Conclusion

Exercise, early screening and intervention for cardiovascular diseases and maintenance of lower LDL-C levels may prevent and slow the progression of frailty.

Exercise to Prevent and Manage Frailty and Fragility Fractures

PURPOSE OF REVIEW

This review identifies exercise-based recommendations to prevent and manage frailty and fragility fractures from current clinical practice guidelines. We also critically assess recently published literature in relation to exercise interventions to mitigate frailty and fragility fractures.

RECENT FINDINGS

Most guidelines presented similar recommendations that included the prescription of individually tailored, multicomponent exercise programs, discouragement of prolonged sitting and inactivity, and combining exercise with optimal nutrition. To target frailty, guidelines recommend supervised progressive resistance training (PRT). For osteoporosis and fragility fractures, exercise should include weight-bearing impact activities and PRT to target bone mineral density (BMD) at the hip and spine, and also incorporate balance and mobility training, posture exercises, and functional exercise relevant to activities of daily living to reduce falls risk. Walking as a singular intervention has limited benefits for frailty and fragility fracture prevention and management. Current evidence-based clinical practice guidelines for frailty, osteoporosis, and fracture prevention recommend a multifaceted and targeted approach to optimise muscle mass, strength, power, and functional mobility as well as BMD.

Assessment of Frailty Index at 66 Years of Age and Association With Age-Related Diseases, Disability, and Death Over 10 Years in Korea

Importance

A frailty index has been proposed as a measure of aging among older individuals. However, few studies have examined whether a frailty index measured at the same chronologic age at younger ages could forecast the development of new age-related conditions.

Objective

To examine the association of the frailty index at 66 years of age with incident age-related diseases, disability, and death over 10 years.

Design, Setting, and Participants

This retrospective nationwide cohort study used the Korean National Health Insurance database to identify 968 885 Korean individuals who attended the National Screening Program for Transitional Ages at 66 years of age between January 1, 2007, and December 31, 2017. Data were analyzed from October 1, 2020, to January 2022.

Exposures

Frailty was defined using a 39-item frailty index ranging from 0 to 1.00 as robust (<0.15), prefrail (0.15-0.24), mildly frail (0.25-0.34), and moderately to severely frail (≥0.35).

Main Outcomes and Measures

The primary outcome was all-cause death. Secondary outcomes were 8 age-related chronic diseases (congestive heart failure, coronary artery disease, stroke, type 2 diabetes, cancer, dementia, fall, and fracture) and disability qualifying for long-term care services. Cox proportional hazards regression and cause-specific and subdistribution hazards regression were used to examine hazard ratios (HRs) and 95% CIs for the outcomes until the earliest of date of death, the occurrence of relevant age-related conditions, 10 years from the screening examination, or December 31, 2019.

Results

Among the 968 885 participants included in the analysis (517 052 women [53.4%]), the majority were classified as robust (65.2%) or prefrail (28.2%); only a small fraction were classified as mildly frail (5.7%) or moderately to severely frail (1.0%). The mean frailty index was 0.13 (SD, 0.07), and 64 415 (6.6%) were frail. Compared with the robust group, those in the moderately to severely frail group were more likely to be women (47.8% vs 61.7%), receiving medical aid insurance for low income (2.1% vs 18.9%), and less active (median, 657 [IQR, 219-1133] vs 319 [IQR, 0-693] metabolic equivalent task [min/wk]). After adjusting for sociodemographic and lifestyle characteristics, moderate to severe frailty was associated with increased rates of death (HR, 4.43 [95% CI, 4.24-4.64]) and new diagnosis of all chronic diseases, including congestive heart failure (adjusted cause-specific HR, 2.90 [95% CI, 2.67-3.15]), coronary artery disease (adjusted cause-specific HR, 1.98 [95% CI, 1.85-2.12]), stroke (adjusted cause-specific HR, 2.22 [95% CI, 2.10-2.34]), diabetes (adjusted cause-specific HR, 2.34 [95% CI, 2.21-2.47]), cancer (adjusted cause-specific HR, 1.10 [95% CI, 1.03-1.18]), dementia (adjusted cause-specific HR, 3.59 [95% CI, 3.42-3.77]), fall (adjusted cause-specific HR, 2.76 [95% CI, 2.29-3.32]), fracture (adjusted cause-specific HR, 1.54 [95% CI, 1.48-1.62]), and disability (adjusted cause-specific HR, 10.85 [95% CI, 10.00-11.70]). Frailty was associated with increased 10-year incidence of all the outcomes, except for cancer (moderate to severe frailty adjusted subdistribution HR, 0.99 [95% CI, 0.92-1.06]). Frailty at 66 years of age was associated with greater acquisition of age-related conditions (mean [SD] conditions per year for the robust group, 0.14 [0.32]; for the moderately to severely frail group, 0.45 [0.87]) in the next 10 years.

Conclusions and Relevance

The findings of this cohort study suggest that a frailty index measured at 66 years of age was associated with accelerated acquisition of age-related conditions, disability, and death over the next 10 years. Measuring frailty at this age may offer opportunities to prevent age-related health decline.

Effective primary care attenuates the association between frailty and hospital admission in old age: the ELSI-Brazil

BACKGROUND

Frailty is a multidimensional syndrome leading to a higher hospitalization. However, few studies explicitly analyze whether measures of effective primary care modify the relationship between frailty and hospital admission.

METHODS

This cross-sectional study included data from the second wave of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), a representative community-based study with older adults aged 50 years and over, conducted in 2019-2021. Self-reported hospital admission in the past 12 months was the outcome. Frailty included the 5 phenotypic criteria: weight loss, exhaustion, low physical activity, weakness, and slowness. The effective primary care index included 12 attributes indicators, continuously. Statistical analyzes comprised logistic regression.

RESULTS

Among the 7,436 study participants, frailty (odds ratio [OR] 2.17; 95% confidence intervals [95% CI] 1.31-3.62) and effective primary care index (OR 1.10; 95% CI 1.03-1.16) were positively associated with higher hospitalization. Interaction revealed that while effective primary care was positively associated with hospitalization, this association was different among frail older adults (OR 0.80; 95% CI 0.65-0.99). After stratification by frailty status, positive association with hospitalization remained only among prefrail and nonfrail individuals. The predicted probability of hospitalization tended to decrease along with higher primary care index values among frail older adults and became similar to prefrail/nonfrail at the highest end of the scale.

CONCLUSIONS

Effective primary care decreases the likelihood of hospital admission among frail older adults. Interventions for delaying frailty should be initiated in primary care along with policies to strengthen primary care's organizational and provider/team-level attributes.

Association of metformin exposure with low risks of frailty and adverse outcomes in patients with diabetes

BACKGROUND

Diabetes is an independent risk factor of frailty, which increases adverse outcomes in patients with diabetes. Metformin is a common antidiabetic drug in clinical practice. Insulin resistance and chronic inflammation are the two common mechanisms of diabetes and frailty, as well as the main targets of metformin. Research suggested that metformin has anti-aging potential. However, few studies focus on the relationship between metformin and frailty. Thus, we aimed to explore whether metformin was associated with a low risk of frailty and other adverse outcomes in diabetic patients.

METHODS

A total of 422 patients (≥ 40 years old) with type 2 diabetes were recruited. Frailty was defined by the Fried phenotype. General information and metformin exposure data were collected, and comprehensive geriatric assessment and laboratory tests were performed. Follow-up was conducted after 4.5 years. The primary outcome was the combined endpoint of cardiovascular events, cerebrovascular events, readmission, and death. Binary logistic regression analysis was used to analyze the association of metformin with frailty. Survival analysis was performed using Cox proportional hazards models.

RESULTS

The total prevalence of frailty was 19.4% among the participants with diabetes. 13.1% of patients in the metformin group and 28.2% in the non-metformin group had frailty. Metformin was inversely associated with frailty after adjusting for age, sex, duration, blood glucose levels, target organ damage, comorbidities, and polypharmacy. Further longitudinal analysis showed that metformin was also independently associated with a low risk of combined primary outcomes after adjusting for multiple covariables, while frailty was related to an increased risk of the combined primary outcomes. In the non-frail group, metformin was associated with a decreased risk of combined primary outcomes after adjustment for age and sex. However, the protective effect of metformin on adverse outcomes was not found in frail participants with diabetes.

CONCLUSIONS

Metformin use is associated with a reduced risk of frailty. In addition, frailty may attenuate the protective effects of metformin on adverse outcomes in diabetic patients. The early identification and prevention of frailty progression may help enhance the benefits of metformin in patients with diabetes.

Critical Appraisal of the Concept Frailty: Rating of Frailty in Elderly People has Weak Scientific Basis and should not be Used for Managing Individual Patients

The concept frail elderly has been used to highlight the biological, rather than chronological, age. International and national bodies recommend that individuals over age 70 who visit healthcare facilities should be screened for frailty. There are important objections to the concept. Diagnostics: 'Frailty' is used for several completely different types of health problems. There are no useful biomarkers, but more than 60 different published rating methods for frailty, where different methods provide very different prevalence of frailty and also do not identify the same groups of elderly people. There is significant overlap between Clinical Frailty Scale- scores and activity of daily living (ADL)-scores. There is no gold standard method against which published frailty rating scales can be validated. It is unclear when, where and how often screening for frailty should occur in healthcare. Treatment: The evidence for treatment of frailty is very weak. A recent systematic overview found that the 21 included randomised, controlled studies (RCTs) were very heterogeneous as regards inclusion/exclusion criteria, how the condition of frailty was defined, what treatment was given and what health outcomes were assessed. In addition, there are often problems with the quality of the studies. The lack of a clear definition and evidence-based treatment of frailty means that it is inappropriate to introduce assessments of frailty in individual elderly patients in health care.

Clinical frailty scale score during geriatric rehabilitation predicts short-term mortality: RESORT cohort study

BACKGROUND

Frailty is associated with poor health outcomes, such as functional decline and institutionalization. The Clinical Frailty Scale (CFS) is a judgement-based frailty assessment tool developed to identify frail adults and assess level of frailty.

OBJECTIVES

We aimed to determine the association between CFS at admission and discharge, admission-discharge change, and mortality in individuals admitted to geriatric rehabilitation.

METHODS

REStORing health of acutely unwell adulTs (RESORT) is a longitudinal, observational inception cohort of consecutive individuals admitted to geriatric rehabilitation at the Royal Melbourne Hospital, Melbourne, Australia. The CFS was assessed at admission and discharge from geriatric rehabilitation. Logistic regression was used to examine the association between CFS score at admission and in-hospital mortality. Cox proportional hazards regression analysis was used to analyse associations between CFS at admission and discharge, admission-to-discharge change, and 3-month and 1-year mortality.

RESULTS

A total of 1766 participants were included: median age was 83.4 years (Interquartile range [IQR] 77.6-88.4), 57% were female, median length of stay in geriatric rehabilitation was 20 days (13.8-31.7) and median CFS score was 6 (5-7) at both admission and discharge. Increased CFS score was associated with in-hospital mortality (odds ratio [OR] 1.8, 95% CI 1.4-2.4), 3-month mortality and 1-year mortality (admission CFS: hazard ratio [HR] 1.4, 95% CI 1.2-1.6; discharge CFS: HR 1.4, 95% CI 1.2-1.7). Risk of 3-month mortality was increased when CFS score increased from admission to discharge (HR 2.1, 95% CI 1.2-3.8) as compared with when it decreased.

CONCLUSION

CFS score at admission and discharge was associated with post-discharge mortality in individuals admitted to geriatric rehabilitation. These findings support the use of the CFS in clinical settings to assist clinical characterisation and decision making.

Impact of Exercise and Cognitive Stimulation Therapy on Physical Function, Cognition and Muscle Mass in Pre-Frail Older Adults in the Primary Care Setting: A Cluster Randomized Controlled Trial

OBJECTIVES

Multicomponent exercise program have shown to improve function and cognition in older adults but studies on pre-frail older adults in the primary care setting are limited. This study aimed i) to evaluate impact of 6 months exercise (Ex) versus complementary effect of 3 months of cognitive stimulation therapy (CST) to 6 months of Ex (Ex+CST) on physical function, muscle mass and cognition versus control group at 3, 6 and 12 months ii) inflammatory biomarkers such as Interleukin-6 (IL-6) and Tumor Necrosis Factor Alpha (TNF-α).

DESIGN

Cluster randomised control trial.

SETTING AND INTERVENTION

Pre-frail older adults ≥ 65 years attending primary care clinic. Two intervention groups i) Ex 6 months ii) CST 3 months with Ex 6 months.

MEASUREMENTS

At 0, 3, 6 and 12 months, questionnaires (on demographics, physical function, cognition, and depression) were administered and physical function assessment (gait speed, short physical performance battery (SPPB) test, handgrip strength, five times sit-to-stand (5x-STS)) was conducted. Muscle mass and its surrogates such as phase angle and body cell mass were measured using bioelectrical impedance analysis machine. Inflammatory biomarkers were measured at 0 and 3 months.

RESULTS

Data from 190 participants was analysed at 3 months (111 control, 37 Ex and 41 Ex+CST). At 3 months, significant improvement in cognition was seen only in the Ex+CST group whereas improvements in depression, gait speed, SPPB and 5x-STS were seen in both the Ex and Ex+CST groups. At 6 months, the Ex+CST group improved in cognition and depression whereas improvement in frailty and muscle mass indices were seen in both the interventions groups. At 12 months, both the interventions groups had better perceived health, gait speed and less decline in muscle mass compared with control groups. Both the Ex and Ex+CST had significant association with TNF-α at 3 months (β -2.71 (95% CI -4.80 - -0.62); p = 0.012 and β -1.74 (95% CI -3.43 - -0.06); p = 0.043 respectively).

CONCLUSION

Combined Ex+CST had significant improvement in cognition whereas the intervention groups improved in depression, physical function, muscle mass, frailty, perceived health and TNF-α levels. With growing evidence of the benefits of multicomponent interventions at primary care level, incorporating it into mainstream care with action plans on long-term sustainability and scalability should be a priority for every country.

The Applicability of the ESPEN and EASO-Defined Diagnostic Criteria for Sarcopenic Obesity in Japanese Patients after Stroke: Prevalence and Association with Outcomes

Sarcopenic obesity is of growing research and clinical interest; however, validated diagnostic criteria are lacking. We therefore aimed to examine the prevalence of sarcopenic obesity as diagnosed by the criteria recently proposed by the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Association for the Study of Obesity (EASO), and its association with outcomes among patients after stroke. This study was based on a cohort of 760 Japanese patients after stroke admitted to a post-acute rehabilitation hospital. Sarcopenic obesity was diagnosed at admission according to the ESPEN and EASO criteria using reference values specific to Asians. Outcomes included the motor domain of the functional independence measure (FIM-motor) and the food intake level scale (FILS) at discharge. Multivariate linear regression models were used to assess the associations between sarcopenic obesity and outcomes. Among 760 patients (median age, 73 years; 352 women and 408 men), sarcopenic obesity was diagnosed in 34 patients (4.5%; 5.4% of women and 4.1% of men). In multivariate analyses, sarcopenic obesity was independently and negatively associated with FIM-motor (β = −0.048, p = 0.031) and FILS at discharge (β = −0.095, p = 0.046) in women. In contrast, in men, sarcopenic obesity showed an independent negative association with FIM-motor at discharge (β = −0.117, p < 0.001) but no statistically significant association with FILS at discharge (β = −0.004, p = 0.323). In conclusion, the prevalence of sarcopenic obesity diagnosed by the ESPEN and EASO-defined criteria was as low as 4.5% among Japanese patients after stroke. Furthermore, sarcopenic obesity was negatively associated with improvements in activities of daily living and dysphagia.

[PAPPS update on older people 2022]

This article examines the latest available evidence on preventive activities in the elderly, including sleep disorders, physical exercise, deprescription, cognitive disorders and dementias, nutrition, social isolation and frailty.

Development and Validation of the Chinese Frailty Screening Scale: A Study among Community-Dwelling Older Adults in Shanghai

BACKGROUND

Based on intrinsic capacity (IC) as defined by the World Health Organization, an accelerated decline may be an important precursor of frailty among older adults; however, there is a lack of validated instruments that both screen for frailty and monitor IC. This study aims to develop a comprehensive and acculturative frailty screening scale to determine healthy aging among older Chinese adults.

SETTING AND PARTICIPANTS

A cross-sectional and a cohort study both based on community-dwelling older adults aged 65 and older.

METHODS

This study mainly consisted of two parts. First, the selection and revision of 20 items related to frailty based on a literature review, expert consultation, and stakeholder analysis; second, a cross-sectional study was conducted to simplify the scale and test the reliability and validity of the new frailty screening tool. The fatigue, resistance, ambulation, illness, and loss of weight (FRAIL) scale, the Tilburg frailty indictor (TFI), and a 49-item Frailty Index (FI) were investigated as criteria. Additionally, a cohort study in Shanghai was conducted to verify the predictive validity of the new screening scale. The disability measured by the activity of daily living (ADL), instrumental activity of daily living (IADL) and all-cause mortality were documented as outcomes.

RESULTS

A 10-item Chinese frailty screening scale (CFSS-10) was successfully developed and validated. It presented a Cronbach's α of 0.63 and an intraclass correlation coefficient of 0.73, which indicated good reliability. Taking the other frailty tools as criteria, Kappa values of 0.54-0.58 and an area under the curve of 0.87-0.91 showed good validity. The results of the log-binomial and Poisson models showed a high score, which predicted a higher risk of disability and all-cause mortality. An optimal cut-off point of 5 gave an excellent prediction of one-year disability.

CONCLUSIONS

The CFSS-10 has good validity and reliability as a quick and acculturative frailty screening scale for community-dwelling older adults in Shanghai. It may also supplement existing frailty screening tools.

Simpler modified fried frailty scale as a practical tool to evaluate physical frailty: Methodological report for its cross-cultural adaptation and validation

Frailty is a common geriatric syndrome that indicates homeostenosis and increased risk of disability and mortality. It is amenable to intervention when detected. Hence, screening frailty is of utmost importance to preserve quality-of-life and function in older age. Simpler Modified Fried Frailty Scale is a very practical frailty screening tool that has recently been introduced and has rooted from the original Fried Scale. It is developed in Turkish and has been shown to predict mortality in nursing home residents. Considering the variety of languages in Europe, it seems valid to adapt and validate this tool in different European languages. Thereby, it is expected that clinicians will have the possibility to screen for frailty more quickly and easily in their practice across many countries. This report is written to explain the details of the final consensus methodology suggested for Simpler Modified Fried Frailty Scale validation in order to guide and help the research teams in their studies.

[Frailty in primary care: Diagnosis and multidisciplinary management]

El envejecimiento poblacional se asocia a un mayor uso de recursos sociales sanitarios, asociados a la mayor morbimortalidad y discapacidad de este grupo etario. La fragilidad es un síndrome geriátrico previo a la aparición de la dependencia funcional, que permite la identificación de individuos de mayor riesgo de dependencia, institucionalización, efectos adversos de fármacos, mortalidad y otros eventos negativos de salud. Este síndrome es potencialmente reversible con una intervención multicomponente. La atención primaria de salud es el lugar preferente para el diagnóstico y seguimiento de la fragilidad, a través de escalas como la FRAIL scale, el fenotipo de Fried o modelos de acumulación de déficits. Para el seguimiento se precisa la intervención multidimensional y coordinada de diferentes profesionales sanitarios y sociales, con la implicación del paciente y su familia. Se debe fomentar la investigación para determinar las intervenciones más eficaces y los cursos clínicos más frecuentes.

Perspectives of older adults, caregivers, healthcare providers on frailty screening in primary care: a systematic review and qualitative meta-synthesis

Background

Screening is often recommended as a first step in frailty management. Many guidelines call to implicate frailty screening into practice in the primary care setting. However, few countries or organizations implement it. Understanding and clarifying the stakeholders’ views and issues faced by the implementation is essential to the successful implementation of frailty screening. However, the systematic review on stakeholders’ views of frailty screening in primary care is decidedly limited. Our objective was to explore the perspective of older adults, caregivers, and healthcare providers on frailty screening and determine the enablers and barriers to implementing frailty screening in primary care.

Methods

A systematic search of six databases and other resources was conducted following JBI’s three-step search strategy. The search resulted in 7362 articles, of which 97 were identified for further assessment according to the inclusion criteria. After the full-text screening, quality assessment and data extraction were carried out using the tools from Joanna Briggs Institute (JBI). Moreover, reviewers used the approach of meta-aggregative of JBI to analyze data and synthesis the findings.

Results

Six studies were included. A total of 63 findings were aggregated into 12 categories and then further grouped into three synthesized findings:1) capacity of healthcare providers and older adults; 2) opportunity in the implementation of frailty screening; 3) motivation in the implementation of frailty screening. These themes can help identify what influences the implementation of screening from the perspective of stakeholders.

Conclusions

This meta-synthesis provides evidence on the barriers and enablers of frailty screening in primary care, from the aspects of psychological, physical, social, material, etc. However, stakeholder perspectives of frailty screening have not been adequately studied. More research and efforts are needed to explore the influencing factors and address the existing barriers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03173-6.

The role of the district nurse in screening and assessment for frailty

An ageing population is leading to greater demands on healthcare services; investments are being made to allow complex care to be given in patient's homes by community care staff, as highlighted in the NHS Long Term Plan (2019). Frailty is often identified in secondary care when acute crisis is hit; frailty does not suddenly occur and will happen over time. This article aims to explore community screening, the assessment processes of frailty and the role the district nurse has. It also addresses how working collaboratively with the wider multidisciplinary team to earlier identify service users with frailty can assist in improving patient outcomes by empowering and supporting service users to remain at home. Recognising continual improvement to service users' care and changes in practice should be considered and disseminated. based upon best available evidence.

A multifactorial interdisciplinary intervention to prevent functional and mobility decline for more participation in (pre-)frail community-dwelling older adults (PromeTheus): study protocol for a multicenter randomized controlled trial

BACKGROUND

Age-related decline in physical capacity can lead to frailty, associated with an increased vulnerability to adverse health outcomes and greater healthcare utilization. In an aging population, effective strategies to prevent physical decline and frailty, and preserve independence are needed. Prevention programs for vulnerable community-dwelling older adults are, however, often not yet established and implemented in routine practice. Research on the feasibility, implementation, and (cost-)effectiveness of multifactorial, interdisciplinary intervention programs that take advantage of available services of healthcare providers is also limited. The main aim of this study is to evaluate the effectiveness of such an intervention program (PromeTheus) to prevent functional and mobility decline for more participation in community-dwelling (pre-)frail older adults.

METHODS

The study is designed as a three-center, randomized controlled trial with a 12-month intervention period. Four hundred community-dwelling (pre-)frail (Clinical Frailty Scale score 4-6) older adults (≥70 years) will be randomized in a 1:1 ratio to the intervention group (IG) or the control group (CG). The IG will receive the PromeTheus program consisting of obligatory home-based physical exercises (Weight-bearing Exercise for Better Balance) accompanied by physiotherapists and facultative counseling services (person-environment-fit, coping with everyday life, nutrition, group-based activities) delivered via existing healthcare structures (e.g., social workers, nutritionists). The CG will receive usual care and a one-time counseling session on recommendations for physical activity and nutrition. Primary outcomes assessed at months 6 and 12 are the function component of the Late-Life Function and Disability Instrument and the University of Alabama at Birmingham Life-Space Assessment. Secondary outcomes are disability, physical capacity and activity, frailty, nutritional status, falls, fear of falling, health status, and psychosocial components. Process and economic evaluations are also conducted. Primary statistical analyses will be based on the intention-to-treat principle.

DISCUSSION

Compared to usual care, the PromeTheus program is expected to result in higher function and mobility, greater independence and lower need for care, and more participation. As the PromeTheus program draws on existing German healthcare structures, its large-scale translation and delivery will be feasible, if evidence of (cost-)effectiveness and successful implementation can be demonstrated.

TRIAL REGISTRATION

German Clinical Trials Register, . Registered on March 11, 2021.

Direct and Indirect Effects of COVID-19 in Frail Elderly: Interventions and Recommendations

Frailty is a state of vulnerability to stressors because of a decreased physiological reserve, resulting in poor health outcomes. This state is related to chronic conditions, many of which are risk factors for outcomes in elderly patients having SARS-COV-2. This review aims to describe frailty as a physiological vulnerability agent during the COVID-19 pandemic in elderly patients, summarizing the direct and indirect effects caused by the SARS-COV-2 infection and its prognosis in frail individuals, as well as the interventions and recommendations to reduce their effects. Cohort studies have shown that patients with a Clinical Frailty Scale higher than five have a higher risk of mortality and use of mechanical ventilation after COVID-19; nonetheless, other scales have also associated frailty with longer hospital stays and more severe forms of the disease. Additionally, the indirect effects caused by the pandemic have a negative impact on the health status of older people. Due to the above, a holistic intervention is proposed based on a comprehensive geriatric assessment for frail patients (preventive or post-infection) with emphasis on physical activity and nutritional recommendations, which could be a potential preventive intervention in viral infections by COVID-19.