Bidirectional relationship between insomnia and frailty in older adults: A 2-year longitudinal study

Nocturia and frailty in older adults: a scoping review

BACKGROUND

More than one in two older people wake up several times a night to urinate. Far from being a minor inconvenience, nocturia is associated with poor health outcomes. Given the importance of sleep as a foundation for resilience and healthy ageing, nocturia may promote the development of frailty, which is inextricably linked to physical decline, disability, and mortality. The aim of this scoping review was to collate published evidence on the relationship between nocturia and frailty, using the methodological framework of Arksey and O'Malley, together with the Joanna Briggs Institute methodology as guidance (OSF registration: osf.io/d5ct7).

METHODS

Relevant publications were retrieved via PubMed, Embase, the Cochrane Library and Google Scholar. The Rayyan tool was used to facilitate the screening process. Data were extracted by two independent reviewers. 250 publications were initially identified, of which 87 met the eligibility criteria.

RESULTS

Most of the evidence came from cross-sectional studies, most of which had been published within the last 5 years. The researchers were diverse, with 27% having a geriatric background. Only few publications established a clear association between nocturia and frailty. Other topics included: the association between nocturia and poor sleep quality and duration; the association between sleep and frailty; the association between frailty, multimorbidity, and age-related changes in the lower urinary tract.

CONCLUSION

The findings emphasize the increasing interest and interdisciplinary nature of research into the relationship between frailty, nocturia, lower urinary tract symptoms, and sleep disturbances. Further research is required to enhance understanding, establish causality, and identify potential therapeutic approaches.

Examining the role of living alone and loneliness in predicting health-related quality of life: results from the Healthy Aging Longitudinal Study in Taiwan (HALST)

PURPOSE

This study aimed to investigate the distinct yet interconnected aspects of social isolation, namely living alone and loneliness, and their individual and combined effects on predicting health-related quality of life (HRQoL).

METHODS

A comprehensive analysis, encompassing both cross-sectional and longitudinal approaches, was conducted using a nationally representative sample of 5644 community-dwelling adults aged 55 and older from the Healthy Aging Longitudinal Study in Taiwan (HALST).

RESULTS

Baseline data revealed that 9% of the sample reported living alone, while 10.3% reported experiencing loneliness, with 2.5% reporting both living alone and feeling lonely. Regression analyses consistently demonstrated that loneliness was significantly associated with concurrent and subsequent lower physical (PCS) and mental (MCS) component of HRQoL. Conversely, additional analyses indicated that living alone could indirectly exacerbate the adverse effects of loneliness or contribute to prolonged feelings of loneliness, subsequently predicting lower HRQoL after 3.2 year.

CONCLUSION

In terms of practical implications, interventions and policies aiming to enhance HRQoL in older adults should give particular attention to those who report feelings of loneliness, especially individuals living alone.

The causal relationship between sleep disturbances and the risk of frailty: a two-sample Mendelian randomization study

OBJECTIVE

Adequate sleep is closely related to people's health. However, with increasing age, the quality of sleep worsens. At the same time, among elderly individuals, frailty is also a disturbing factor, which makes elderly individuals more vulnerable to negative factors. To explore the relationship between the two, we conducted this study.

METHODS

In this paper, independent genetic variations related to insomnia, sleep duration and daytime sleepiness were selected as IVs, and related genetic tools were used to search published genome-wide association studies for a two-sample Mendelian randomization (TSMR) analysis. The inverse-variance weighted (IVW) method was used as the main Mendelian randomization analysis method. Cochran's Q test was used to test heterogeneity, MR‒Egger was used to test horizontal pleiotropy, and the MR-PRESSO test was used to remove outliers.

RESULTS

According to our research, insomnia (OR = 1.10, 95% CI 1.03-1.17, P = 2.59e-97), long sleep duration (OR = 0.66, 95% CI 0.37-1.17, P = 0.02), short sleep duration (OR = 1.30, 95% CI 1.22-1.38, P = 2.23e-17) and daytime sleepiness (OR = 1.49, 95% CI 1.25-1.77, P = 0.96e-4) had a bidirectional causal relationship with frailty.

CONCLUSIONS

Our research showed that there is a causal relationship between sleep disturbances and frailty. This result was obtained by a TSMR analysis, which involves the use of genetic variation as an IV to determine causal relationships between exposure and outcome. Future TSMR studies should include a larger sample for analysis.

Investigating the shared genetic architecture between frailty and insomnia

Background

The epidemiological association between frailty and insomnia is well established, yet the presence of a common genetic etiology is still uncertain. Further exploration is needed to ascertain the causal relationship between frailty and insomnia.

Methods

Utilizing data obtained from genome-wide association studies (GWAS) summaries, we utilized the linkage disequilibrium score regression (LDSC) to determine the genetic correlation existing between frailty and insomnia. The determination of causality was achieved through the application of two-sample Mendelian randomization. We investigated the enrichment of single nucleotide polymorphism (SNP) at various tissue types utilizing stratified LD score regression (S-LDSC) and multimarker analysis of genome annotation (MAGMA). Common risk SNPs were identified using Multi-Trait Analysis of GWAS (MTAG) and Cross-Phenotype Association (CPASSOC). We further investigated the expression profiles of risk genes in tissues using Summary-data-based Mendelian randomization(SMR) based on pooled data, to explore potential functional genes.

Results

Our findings indicated a significant genetic correlation between frailty and insomnia, highlighting SNPs sharing risk (rs34290943, rs10865954), with a pronounced correlation in the localized genomic region 3p21.31. Partitioned genetic analysis revealed 24 functional elements significantly associated with both frailty and insomnia. Furthermore, mendelian randomization revealed a causal connection between frailty and insomnia. The genetic correlation between frailty and insomnia showed enrichment in 11 brain regions (S-LDSC) and 9 brain regions (MAGMA), where four functional genes (RMB6, MST1R, RF123, and FAM212A) were identified.

Conclusion

This study suggests the existence of a genetic correlation and common risk genes between frailty and insomnia, contributing to a deeper comprehension of their pathogenesis and assists in identifying potential therapeutic targets.

Cross-lagged relationship between sleep quality and sense of coherence and the moderating role of mastery in older adults

The aims of this study were to explore the predictive relationship between sleep quality and sense of coherence (SOC) and to examine a possible moderating role of mastery in this relationship. A three-wave longitudinal design was employed using a sample of 304 older adults aged 55-87 years old. Cross-lagged panel analyses and moderating effect analyses showed that sleep quality can predict the levels of SOC 6 months later, whereas SOC cannot predict sleep quality 6 months later. In addition, mastery can moderate the effect of sleep quality on SOC. Specifically, the lagged effects of sleep quality on SOC in older adults who had low levels of mastery were stronger than in those who had high levels of mastery. Overall, these findings provide valuable insights for understanding the predictive relationship between sleep quality and SOC and emphasise the moderating role of mastery. Also, our results offer important implications for enhancing the SOC in older adults by improving sleep quality and mastery.

To Be Frail or Not to Be Frail: This Is the Question-A Critical Narrative Review of Frailty

Many factors have contributed to rendering frailty an emerging, relevant, and very popular concept. First, many pandemics that have affected humanity in history, including COVID-19, most recently, have had more severe effects on frail people compared to non-frail ones. Second, the increase in human life expectancy observed in many developed countries, including Italy has led to a rise in the percentage of the older population that is more likely to be frail, which is why frailty is much a more common concern among geriatricians compared to other the various health-care professionals. Third, the stratification of people according to the occurrence and the degree of frailty allows healthcare decision makers to adequately plan for the allocation of available human professional and economic resources. Since frailty is considered to be fully preventable, there are relevant consequences in terms of potential benefits both in terms of the clinical outcome and healthcare costs. Frailty is becoming a popular, pervasive, and almost omnipresent concept in many different contexts, including clinical medicine, physical health, lifestyle behavior, mental health, health policy, and socio-economic planning sciences. The emergence of the new "science of frailty" has been recently acknowledged. However, there is still debate on the exact definition of frailty, the pathogenic mechanisms involved, the most appropriate method to assess frailty, and consequently, who should be considered frail. This narrative review aims to analyze frailty from many different aspects and points of view, with a special focus on the proposed pathogenic mechanisms, the various factors that have been considered in the assessment of frailty, and the emerging role of biomarkers in the early recognition of frailty, particularly on the role of mitochondria. According to the extensive literature on this topic, it is clear that frailty is a very complex syndrome, involving many different domains and affecting multiple physiological systems. Therefore, its management should be directed towards a comprehensive and multifaceted holistic approach and a personalized intervention strategy to slow down its progression or even to completely reverse the course of this condition.

Sleep quality, frailty and overall health among community-dwelling older people: A longitudinal study

AIMS

The aims of the study were to describe sleep quality among community-dwelling older people; determine the association between sleep quality (total and multidimensional), frailty and overall health; study frailty as a mediator in the association between sleep quality and overall health.

DESIGN

This longitudinal, correlative study used data from 2020 to 2022.

METHODS

A total of 181 community-dwelling older people in a city in Southeast China were assessed twice. Sleep quality was measured using the Pittsburgh Sleep Quality Index at Time 1 (year 2020); frailty was measured using the FRAIL scale, and overall health was measured using the EuroQol visual analogue scale at Time 1 and 2 (1 year later). Associations and indirect effects were examined using linear regression analyses using the PROCESS Macro (Model 4).

RESULTS

Poor sleep quality (higher scores) was associated with increased frailty over time (total scale), as well as subjective sleep quality, sleep duration, sleep efficiency and daytime dysfunction. Mediation analyses indicated that frailty change had an indirect effect on the association between sleep quality total score Time (T) 1 and overall health T2 and between the dimensions subjective sleep quality, sleep duration, sleep efficiency and daytime dysfunction and overall health. All analyses were adjusted for age, multimorbidity and overall health T1.

CONCLUSIONS

Poor sleep quality is a common problem associated with poor overall health after 1 year, and the progression of frailty mediates this association.

IMPACT

The findings provide a better understanding of the association between sleep quality and overall health and elucidate the mediating effect of frailty. Regular screening and effective treatment by healthcare providers for sleep problems and frailty in older people are necessary to improve their overall health and enhance healthy ageing.

PATIENT OR PUBLIC CONTRIBUTION

Participants in the study provided the data used for all data analysis in the manuscript. Patient or public were not involved in data analysis, interpretation or manuscript preparation. Staff in the community health centre helped with data collection.

Bidirectional Associations Between Sleep Quality and Grip Strength and the Mediating Role of Depression: Evidence From Two Nationally Representative Cohorts

BACKGROUND

Although studies have demonstrated associations between sleep quality (SQ) and grip strength (GS) in older adults, the direction and underlying mechanisms of this relationship are yet to be better delineated. We aimed to longitudinally investigate the bidirectional association between SQ and GS and the mediating role of depression in this association.

METHODS

Based on 2 nationally representative samples with people aged ≥50 years from the China Health and Retirement Longitudinal Study (CHARLS; 4 200 participants) and English Longitudinal Study of Ageing (ELSA; 5 922 participants), cross-lagged panel models were employed to examine the potential bidirectional relationships between objectively measured GS and self-reported SQ.

RESULTS

We observed a GS-SQ bidirectional association dominated by GS. After adjusting for potential confounders, a higher GS at T1 predicted better SQ at T2 (ELSA: β = 0.075; CHARLS: β = 0.104, p < .001) and vice versa (ELSA: β = 0.034; CHARLS: β = 0.030, p < .01). Moreover, depression partially mediated the impact of GS on subsequent SQ (ELSA, indirect effect: 0.0057, 95% confidence interval [CI]: 0.0035-0.0084; CHARLS, indirect effect: 0.0086, 95% CI: 0.0051, 0.0131), but not vice versa.

CONCLUSIONS

The results regarding data from both cohorts consistently supported a bidirectional association between GS and SQ and the mediating role of depression in the dominant pathway of this bidirectional relationship. Older adults with a low GS should be made aware of a potentially vicious cycle related to depression that can affect their sleep. Regular screening for depression may help to break this cycle.

Mediating effects of depression on sleep disturbance and frailty in older adult type 2 diabetes patients in the community

Introduction

With the progressive aging of the population, frailty is now a significant challenge in geriatrics research. A growing amount of evidence suggests that sleep disturbance and depression have independent effects on frailty, although the underlying mechanisms are not yet clear. This study aimed to investigate the mediating role of depression in the relationship between sleep disturbance and frailty in older adult patients with type 2 diabetes (T2DM) in the community.

Method

Purposive sampling was used to collect face-to-face data from 342 community-dwelling T2DM patients in Chengdu, Sichuan Province, China, between February and May 2023. The Pittsburgh Sleep Quality Index (PSQI) scale was used to evaluate sleep quality, the Simple Geriatric Depression Scale (GDS-15) was used to evaluate depressive symptoms, and the FRAIL Scale (FRAIL) was used to evaluate frailty. Linear regression equation and bootstrap self-sampling were used to verify the mediating role of depressive symptoms in sleep disturbance and frailty.

Result

The study found that sleep disturbance had a direct positive effect with frailty [β = 0.040, 95% CI: (0.013, 0.069)]. Additionally, depression had a direct positive effect on frailty [β = 0.130, 95% CI: (0.087, 0.173)], and depression was found to partially mediate the relationship between sleep disturbance and frailty.

Conclusion

Poor sleep quality and frailty are common in patients with T2DM. To reduce the frailty of older adult T2DM patients, all levels of society (government, medical institutions, and communities) must pay more attention to mental health. A variety of interventions should be considered to improve sleep quality and depression, which in turn may prevent or control frailty.

Recent developments in frailty identification, management, risk factors and prevention: A narrative review of leading journals in geriatrics and gerontology

Frailty is an age-related clinical condition characterised by an increased susceptibility to stressors and an elevated risk of adverse outcomes such as mortality. In the light of global population ageing, the prevalence of frailty is expected to soar in coming decades. This narrative review provides critical insights into recent developments and emerging practices in frailty research regarding identification, management, risk factors, and prevention. We searched journals in the top two quartiles of geriatrics and gerontology (from Clarivate Journal Citation Reports) for articles published between 01 January 2018 and 20 December 2022. Several recent developments were identified, including new biomarkers and biomarker panels for frailty screening and diagnosis, using artificial intelligence to identify frailty, and investigating the altered response to medications by older adults with frailty. Other areas with novel developments included exercise (including technology-based exercise), multidimensional interventions, person-centred and integrated care, assistive technologies, analysis of frailty transitions, risk-factors, clinical guidelines, COVID-19, and potential future treatments. This review identified a strong need for the implementation and evaluation of cost-effective, community-based interventions to manage and prevent frailty. Our findings highlight the need to better identify and support older adults with frailty and involve those with frailty in shared decision-making regarding their care.

Frailty and Diminished Human Relationships Are Associated with Poor Sleep Quality in Japanese Older Adults: A Cross-Sectional Study

The purpose of this study was to examine the association between sleep quality, frailty, and human relationships in Japanese older adults (aged 65 years and above, excluding those certified as requiring long-term care). This cross-sectional study used a questionnaire survey to gather demographic information, data on frequency of conversation and conversation partners, and employed the following validated instruments: Kihon Checklist (KCL), a Japanese instrument used to determine the care needs and frailty of older adults; the Dysphagia Risk Assessment for Community-Dwelling Elderly (DRACE) scale; Japanese versions of Pittsburgh Sleep Quality Index (PSQI-J); the Geriatric Depression Scale-15 (GDS-15-J); and the University of California Los Angeles Scale (UCLA-J), an instrument to assess loneliness in older adults. The 500 respondents were divided into two groups based on sleep quality (PSQI-J): low sleep quality group (n = 167, 33.4%) and high sleep quality group (n = 333, 66.6%). Our analyses showed that the low sleep quality group had a KCL score of 5.55 ± 2.47, which indicated frailty. Binomial logistic regression analysis identified age, number of diseases under treatment, DRACE, GDS-15-J, and conversation frequency and discussion partner for important matters as factors (p < 0.05) associated with poor sleep quality. These factors could help enhance the detection of frailty and predictability of caregiving needs.

Association between Physical Frailty and Sleep Disturbances among Patients on Hemodialysis: A Cross-Sectional Study

INTRODUCTION

Among patients on hemodialysis (HD), physical frailty and sleep disturbances are not only common but also associated with adverse outcomes. The aim of this study was to evaluate the association between physical frailty and sleep disturbances in patients on HD.

METHODS

This cross-sectional study was conducted from June 2017 to March 2021, with outpatients receiving HD 3 times a week at two dialysis facilities in Japan. Sleep disturbances were identified with the Athens Insomnia Scale (AIS). Physical frailty was defined using the Fried Frailty Phenotype. Patients were classified as "non-frailty (number of frailty components: 0-2)" or "frailty (3-5)." We examined the association of sleep disturbances with physical frailty and its components by performing a logistic regression analysis.

RESULTS

We analyzed 360 patients (mean age 65.6 years; 62% men). Eighty-one patients (23%) were classified into the group with frailty, and the mean AIS score was 5.2 ± 4.2 points. After adjusting for clinical characteristics, increasing the AIS score per 1 point was associated with higher odds of physical frailty (odds ratio, 1.12; 95% confidence interval, 1.05-1.20; p < 0.01). As for the frailty components, exhaustion, low physical activity, and weak grip strength showed an association with sleep disturbances (all p < 0.05).

CONCLUSIONS

Sleep disturbances were independently associated with physical frailty in patients on HD. Future studies are warranted to investigate the causality between physical frailty and sleep disturbances in this population.

Insomnia Impairs Both the Pro-BDNF and the BDNF Levels Similarly to Older Adults with Cognitive Decline: An Exploratory Study

Sleep disorders, including insomnia, are common during aging, and these conditions have been associated with cognitive decline in older adults. Moreover, during the aging process, neurotransmitters, neurohormones, and neurotrophins decrease significantly, leading to the impairment of cognitive functions. In this sense, BDNF, the most abundant neurotrophic factor in the human brain, has been suggested as a potential target for the prevention and improvement of cognitive decline during aging; however, the current evidence demonstrates that the exogenous administration of BDNF does not improve cognitive function. Hence, in the present study, we quantified pro-BDNF (inactive) and BDNF (active) concentrations in serum samples derived from older individuals with insomnia and/or cognitive decline. We used linear regression to analyze whether clinical or sociodemographic variables impacted the levels of BNDF concentration. We observed that insomnia, rather than cognitive decline, is significantly associated with BDNF concentration, and these effects are independent of other variables. To our knowledge, this is the first study that points to the impact of insomnia on improving the levels of BDNF during aging and suggests that opportune treatment of insomnia may be more beneficial to prevent cognitive decline during aging.

Interactions of Insomnia and Sedative-Hypnotic Drug Use Associated with Frailty Over Time Among Older Adults

BACKGROUND

Insomnia and frailty are prevalent in older adults. This study aimed to elucidate the impact of insomnia and sedative-hypnotic use on the frailty rate over time.

METHODS

We used data from community-dwelling older adults (mean ± SD age = 69.4 ± 8.2 years) from the Healthy Aging Longitudinal Study in Taiwan (HALST). A total of 4,744 participants were included in the study and were followed up for an average of 3.2 years. Frailty was assessed using the Fried criteria. Self-reported sleep problems, sedative-hypnotic use, and claims records from the National Health Insurance database were used. The generalized equation estimation (GEE) approach was applied to account for correlations between repeated measures. The average impact of insomnia and drug use on frailty over time was estimated by adjusting for potential confounding factors using the logic link in the GEE approach.

RESULTS

The adjusted odds ratio (OR) of frailty was 1.41 (95% CI: [1.16, 1.72], Z-test statistics Z = 3.39, p <0.001) for insomnia and 1.52 ([1.16, 2.00], Z = 3.00, p = 0.0027) for sedative-hypnotic use. Interactions between insomnia and sedative-hypnotic use with frailty were not statistically significant. Long sleep duration > 8 hours, daytime sleepiness, and sleep apnea was also associated with an increased likelihood of developing frailty. Notably, a dose-response relationship between sedative-hypnotic drug use and frailty was observed.

CONCLUSIONS

Insomnia and sedative-hypnotic use were independently associated with increased frailty. The implementation of nonpharmacological treatments to attenuate insomnia may reduce frailty rates.

The impact of insomnia on frailty and the hallmarks of aging

Throughout the course of life, there are age-related changes in sleep. Despite these normal changes, there is a high percentage of older adults that report sleep dissatisfaction with a high pervasiveness of chronic insomnia, the most common sleep disorder worldwide, with its prevalence being expected to continuously increase due to the growing rates of aging and obesity. This can have different adverse health outcomes, especially by promoting both physical and cognitive decline, which ultimately may aggravate frailty in older adults. Moreover, age-related frailty and sleep dysfunction may have a common mechanism related to the hallmarks of cellular aging. Cellular aging was categorized into nine hallmarks, such as DNA damage, telomere attrition and epigenetic changes. In the context of geriatric and chronic insomnia research, this review aims at discussing the current evidence from both animal models and human cohorts addressing the link between chronic insomnia, the hallmarks of aging and their impact on frailty. Moreover, the most recent research about the putative effect of insomnia therapeutic approaches on hallmarks of aging will be also highlighted.

Maintaining healthy sleep patterns and frailty transitions: a prospective Chinese study

BACKGROUND

Little is known about the effects of maintaining healthy sleep patterns on frailty transitions.

METHODS

Based on 23,847 Chinese adults aged 30-79 in a prospective cohort study, we examined the associations between sleep patterns and frailty transitions. Healthy sleep patterns included sleep duration at 7 or 8 h/d, without insomnia disorder, and no snoring. Participants who persisted with a healthy sleep pattern in both surveys were defined as maintaining a healthy sleep pattern and scored one point. We used 27 phenotypes to construct a frailty index and defined three statuses: robust, prefrail, and frail. Frailty transitions were defined as the change of frailty status between the 2 surveys: improved, worsened, and remained. Log-binomial regression was used to calculate the prevalence ratio (PR) to assess the effect of sleep patterns on frailty transitions.

RESULTS

During a median follow-up of 8.0 years among 23,847 adults, 45.5% of robust participants, and 10.8% of prefrail participants worsened their frailty status, while 18.6% of prefrail participants improved. Among robust participants at baseline, individuals who maintained sleep duration of 7 or 8 h/ds, without insomnia disorder, and no-snoring were less likely to worsen their frailty status; the corresponding PRs (95% CIs) were 0.92 (0.89-0.96), 0.76 (0.74-0.77), and 0.85 (0.82-0.88), respectively. Similar results were observed among prefrail participants maintaining healthy sleep patterns. Maintaining healthy sleep duration and without snoring, also raised the probability of improving the frailty status; the corresponding PRs were 1.09 (1.00-1.18) and 1.42 (1.31-1.54), respectively. Besides, a dose-response relationship was observed between constantly healthy sleep scores and the risk of frailty transitions (P for trend < 0.001).

CONCLUSIONS

Maintaining a comprehensive healthy sleep pattern was positively associated with a lower risk of worsening frailty status and a higher probability of improving frailty status among Chinese adults.