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

[Prevention of frailty]

BACKGROUND

The presence of frailty in older patients increases the risk for adverse health events and for a loss of independence. Measures for the prevention of this geriatric syndrome should be incorporated into routine healthcare.

OBJECTIVE

What types of interventions could be effective in the prevention of frailty and how can preventive strategies be successfully implemented?

METHOD

Narrative review article.

RESULTS

The concept of frailty is multidimensional and potential starting points for a prevention of frailty can be found within different dimensions (e.g., dimensions of physical activity and nutrition, psychosocial dimension). Epidemiological analyses have identified factors that increase or decrease the risk for becoming frail. Evidence from randomized controlled trials that examined the effectiveness of specific interventions in the prevention of frailty is still limited. Based on the available data, interventions using physical exercise appear to be effective in preventing frailty. In primary care in Germany the frailty status of older patients is not yet routinely recorded, which impedes the identification of patients at risk (patients with pre-frailty) and the implementation of targeted preventive strategies. The Integrated Care for Older People (ICOPE) concept of the World Health Organization offers a potential approach to prevent frailty and to promote healthy ageing within the population.

CONCLUSION

The prevention of frailty is possible and reasonable. Comprehensive and targeted preventive strategies are yet to be implemented.

Association between frailty and subsequent disability trajectories among older adults: a growth curve longitudinal analysis from the Survey of Health, Ageing and Retirement in Europe (2004-19)

Frailty is associated with adverse health outcomes in ageing populations, yet its long-term effect on the development of disability is not well defined. The study examines to what extent frailty affects disability trajectories over 15 years in older adults aged 50+. Using seven waves of data from the Survey of Health, Ageing and Retirement in Europe (SHARE), the study estimates the effect of baseline frailty on subsequent disability trajectories by multilevel growth curve models. The sample included 94 360 individuals from 28 European countries. Baseline frailty was assessed at baseline, using the sex-specific SHARE-Frailty-Instrument (SHARE-FI), including weight loss, exhaustion, muscle weakness, slowness, and low physical activity. Disability outcomes were the sum score of limitations in activities of daily living (ADL) and Instrumental ADL (IADL). Analyses were stratified by sex. Over 15 years, baseline frailty score was positively associated with disability trajectories in men [βADL = 0.074, 95% confidence interval (CI) = 0.064; P = .083; βIADL = 0.094, 95% CI = 0.080; P = 0.107] and women (βADL = 0.097, 95% CI = 0.089; P = .105; βIADL = 0.108, 95% CI = 0.097; P = .118). Frail participants showed higher ADL and IADL disability levels, independent of baseline disability, compared with prefrail and robust participants across all age groups. Overall, participants displayed higher levels of IADL disability than ADL disability. Study findings indicate the importance of early frailty assessment using the SHARE-FI in individuals 50 and older as it provides valuable insight into future disability outcomes.

Effect of leisure activity on frailty trajectories among Chinese older adults: a 16-year longitudinal study

BACKGROUND

While the significant association between leisure activities and frailty risk among older adults is well-established, the impact of integrated leisure activity scores and different categories of them on frailty trajectories over time remains unclear.

METHODS

This study utilized longitudinal data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), which enrolled participants aged 65 years and older between 2002 and 2018. Frailty trajectories were derived using group-based trajectory modelling, and based on these trajectories, subjects were classified into various categories. Leisure activity was measured by integrated scores as well as three distinct categories: physically, cognitively, and socially stimulating activity. The effect of leisure activity on frailty trajectories was examined using multinomial logistic regression.

RESULTS

By analysing data from 2,299 older adults, three frailty trajectories were identified: non-frail, moderate progressive, and high progressive. The results indicated that an increase in the score of integrated leisure activity was associated with 11% (odds ratio [OR] 0.89; 95% Confidence Interval [CI] 0.85-0.93) and 14% (OR 0.86; 95% CI 0.80-0.91) decrease in the likelihood of being in the moderate and high progressive frailty trajectories, respectively. Engaging in physically stimulating activity lowered the odds of belonging to the moderate and high progressive trajectory by 43% (OR 0.57; 95% CI 0.40-0.81; OR 0.57; 95% CI 0.36-0.92, respectively). Participation in socially stimulating activity showed a lower odd of being in the moderate progressive trajectory (OR 0.68; 95% CI 0.49-0.93) and the high progressive trajectory (OR, 0.61; 95% CI, 0.39-0.95). The effects of leisure activities on frailty trajectories were observed not to vary by age, education level and retirement status.

CONCLUSIONS

This study suggests that older adults should be encouraged to increase both the amount and variety of their leisure activities. Physically stimulating activities should be considered the primary choice, followed by socially and cognitively stimulating activities.

Prognostic accuracy of eight frailty instruments for all-cause mortality in Australian primary care

AIM

To investigate the ability of eight frailty instruments to accurately predict all-cause mortality and other adverse outcomes in Australian primary care patients.

METHODS

Study participants included adults aged ≥75 years attending one of three primary care clinics in South Australia. Frailty instruments studied were Fried's frailty phenotype (FFP), the Frailty Index (FI) of cumulative deficits, Kihon Checklist (KCL), the Fatigue Resistance Ambulation Illness and Loss of weight (FRAIL) scale, Groningen Frailty Indicator (GFI), PRISMA-7, Reported Edmonton Frail Scale (REFS), and gait speed. Primary outcomes were all-cause mortality at 12- and 24-months. Secondary outcomes included falls, general practice attendance, hospital admission and emergency department (ED) presentation at 12-months.

RESULTS

243 participants (55.6 % female) with a mean (SD) age of 80.2 (4.6) years were included. 29 participants (16.6 %) were classified as frail at baseline by FFP. All frailty instruments demonstrated a significant ability to predict 12- and 24-month mortality. The REFS showed the highest auROC for both 12- and 24-month mortality. The REFS, Frailty Index, Kihon Checklist, FRAIL scale, and gait speed showed excellent discriminative ability for 12-month mortality (auROC ≥ 0.8 - >0.9), while the remainder showed acceptable discrimination. All frailty instruments, with the exception of the GFI, showed an excellent discriminative ability for 24-month mortality (auROC 0.8-<0.9).

CONCLUSIONS

All frailty instruments possessed adequate discriminative ability for all-cause mortality predicting in older primary care patients. Frailty measurement is thus a valuable strategy to identify older patients at risk of mortality and can guide clinical decision-making in primary care settings.

Higher plant-derived nitrate intake is associated with lower odds of frailty in a cross-sectional study of community-dwelling older women

PURPOSE

Dietary nitrate intake is inversely related to numerous contributors towards frailty, including cardiovascular disease and poor physical function. Whether these findings extend to frailty remain unknown. We investigated if habitual nitrate intake, derived from plants or animal-based foods, was cross-sectionally associated with frailty in women.

METHODS

Community-dwelling older Australian women (n = 1390, mean age 75.1 ± 2.7 years) completed a validated semi-quantitative food frequency questionnaire (FFQ). Nitrate concentrations in food were obtained from international nitrate databases. We adopted the Rockwood frailty index (FI) of cumulative deficits comprising 33 variables across multiple health domains (scored 0 to 1), which predicts increased hospitalisation and mortality risk. A FI ≥ 0.25 indicated frailty. Cross-sectional associations between nitrate intake (total plant and animal nitrate, separately) and frailty were analysed using multivariable-adjusted logistic regression models (including lifestyle factors), as part of restricted cubic splines.

RESULTS

A non-linear inverse relationship was observed between total plant nitrate intake and frailty. Compared to women with the lowest plant nitrate intake (Quartile [Q]1), women with greater intakes in Q2 (OR 0.69 95%CI 0.56-0.84), Q3 (OR 0.67 95%CI 0.50-0.90) and Q4 (OR 0.66 95%CI 0.45-0.98) had lower odds for frailty. A nadir in the inverse association was observed once intakes reached ~ 64 mg/d (median Q2). No relationship was observed between total animal nitrate and frailty.

CONCLUSION

Community-dwelling older women consuming low amounts of plant-derived nitrate were more likely to present with frailty. Consuming at least one daily serving (~ 75 g) of nitrate-rich green leafy vegetables may be beneficial in preventing frailty.

The relationship between oral frailty and oral dysbiosis among hospitalized patients aged older than 50 years

OBJECTIVE

This study aimed to clarify the relationship between oral frailty and oral dysbiosis among hospitalized patients aged ≥ 50 years.

METHODS

A prospective observational study was conducted. Number of teeth, masticatory ability, articulatory oral motor skill, tongue pressure, swallowing pressure, and choking were used to assess oral frailty. Saliva samples were collected from the oral cavity for bacterial culture.

RESULTS

A total 103 in patients enrolled and 53.4% suffered from oral frailty. Oral frailty was found to have a 3.07-fold correlation with the presence of Enterobacterales in the oral cavity (p = 0.037), especially in poor articulatory oral motor skill, which showed at greater risk of Enterobacterales isolated from the oral cavity by 5.58-fold (p = 0.01).

CONCLUSION

Half of hospitalized patients was found to have oral frailty that was related to more Enterobacterales in the oral cavity. This evidence suggests that the enhancement of articulatory oral motor skills may serve as a potential strategy for mitigating the presence of Enterobacterales within the oral cavity.

Lingering effects of COVID-19 in the care of perioperative patients

PURPOSE OF REVIEW

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can lead to organ dysfunction and clinical symptoms beyond the acute infection phase. These effects may have significant implications for the management of perioperative patients. The purpose of this article is to provide a systems-based approach to the subacute and chronic effects of SARS-CoV-2 that are most relevant to anesthesiology practice.

RECENT FINDINGS

In 2024, COVID-19 remains a concern for anesthesiologists due ongoing new infections, evolving viral strains, and relatively low rates of booster vaccination in the general population. A growing body of literature describes the post-COVID-19 syndrome in which patients experience symptoms more than 12 weeks after acute infection. Recent literature describes the lingering effects of SARS-CoV-2 infection on all major organ systems, including neurologic, pulmonary, cardiovascular, renal, hematologic, and musculoskeletal, and suggests an increased perioperative mortality risk in some populations.

SUMMARY

This review offers anesthesiologists an organ system-based approach to patients with a history of COVID-19. Recognizing the long-term sequelae of SARS-CoV-2 infection can help anesthesiologists to better evaluate perioperative risk, anticipate clinical challenges, and thereby optimize patient care.

Mobility Device Use and Frailty Progression in Community-Dwelling Older Adults With Mobility Limitations

Objective: Examine the association between mobility device use and changes in a frailty index (FI) over one year in community-dwelling older adults with mobility limitations. Methods: Analyses utilized 2015-2016 data from the National Health and Aging Trends Study community-dwelling older adults (n = 3934). We calculated a validated 40-item deficit accumulation frailty index (FI) in 2015 and 2016 and compared one year change in FI in older adults with/without canes or walkers using multivariable logistic regression. Analyses were repeated with stratification by baseline frailty. Results: Device use was not associated with worsening frailty in the overall cohort, but was associated with worsening frailty in non-frail individuals when stratified by baseline frailty. Discussion: Device use does not worsen frailty in individuals who are frail at baseline. Device users who were not frail at baseline experienced worsening frailty suggesting additional contributing factors to their frailty aside from mobility limitations.

Immunosuppression for older liver transplant recipients

Older liver transplant recipients have a lower risk of acute rejection than younger patients (9% for patients aged ≥65 years versus 23% for those aged 18-34 years) and are more vulnerable to immunosuppression-related complications. The number of liver transplant recipients ≥65 years has risen to 22% in Europe and the US, but limited information is available on the optimal immunosuppressive regimen for these patients. In this review, we discuss the appropriate management of immunosuppressive agents in older adults to minimize adverse events while avoiding acute rejection. The way the body processes drugs greatly depends on age. In the case of calcineurin inhibitor drugs, aging reduces hepatic metabolism, leading to changes in their pharmacokinetics. Corticosteroids also show decreased clearance as the patient ages. In severe cases of hypoalbuminemia, dose adjustment of mycophenolate acid derivatives may be necessary. However, the pharmacokinetic profiles of the mammalian target of rapamycin inhibitors, basiliximab, and rabbit anti-thymocyte globulin remain unaffected by age. Furthermore, age-related frailty may impact drug metabolism and require tailored interventions and closer follow-up. Although there is limited research, elderly liver transplant recipients require less immunosuppression with double or triple-agent regimens, lower exposure to calcineurin inhibitors, and a shorter course of corticosteroids. The usage of mammalian target of rapamycin inhibitors in older transplant populations has not been specifically investigated, and thus their usage should align with indications for younger patient groups.