Factors associated with frailty transition at different follow-up intervals: A scoping review

Impact of frailty in older people on health care demand: simulation modelling of population dynamics to inform service planning

Background

As populations age, frailty and the associated demand for health care increase. Evidence needed to inform planning and commissioning of services for older people living with frailty is scarce. Accurate information on incidence and prevalence of different levels of frailty and the consequences for health outcomes, service use and costs at population level is needed.

Objectives

To explore the incidence, prevalence, progression and impact of frailty within an ageing general practice population and model the dynamics of frailty-related healthcare demand, outcomes and costs, to inform the development of guidelines and tools to facilitate commissioning and service development.

Study design and methods

A retrospective observational study with statistical modelling to inform simulation (system dynamics) modelling using routine data from primary and secondary health care in England and Wales. Modelling was informed by stakeholder engagement events conducted in Hampshire, England. Data sources included the Royal College of General Practitioners Research and Surveillance Centre databank, and the Secure Anonymised Information Linkage Databank. Population prevalence, incidence and progression of frailty within an ageing cohort were estimated using the electronic Frailty Index tool, and associated service use and costs were calculated. Association of frailty with outcomes, service use and costs was explored with multistate and generalised linear models. Results informed development of a prototype system dynamics simulation model, exploring population impact of frailty and future scenarios over a 10-year time frame. Simulation model population projections were externally validated against retrospective data from Secure Anonymised Information Linkage.

Study population

The Royal College of General Practitioners Research and Surveillance Centre sample comprised an open cohort of the primary care population aged 50 + between 2006 and 2017 (approx. 2.1 million people). Data were linked to Hospital Episode Statistics data and Office for National Statistics death data. A comparable validation data set from Secure Anonymised Information Linkage was generated.

Baseline measures

Electronic Frailty Index score calculated annually and stratified into Fit, Mild, Moderate and Severe frailty categories. Other variables included age, sex, Index of Multiple Deprivation score, ethnicity and Urban/rural.

Outcomes

Frailty transitions, mortality, hospitalisations, emergency department attendances, general practitioner visits and costs.

Findings

Frailty is already present in people aged 50-64. Frailty incidence was 47 cases per 1000 person-years. Frailty prevalence increased from 26.5% (2006) to 38.9% (2017). Older age, higher deprivation, female sex, Asian ethnicity and urban location independently predict frailty onset and progression; 4.8% of 'fit' people aged 50-64 years experienced a transition to a higher frailty state in a year, compared to 21.4% aged 75-84. Individual healthcare use rises with frailty severity, but Mild and Moderate frailty groups have higher overall costs due to larger population numbers. Simulation projections indicate frailty will increase by 7.1%, from 41.5% to 48.7% between 2017 and 2027, and associated costs will rise by £5.8 billion (in England) over an 11-year period.

Conclusions

Simulation modelling indicates that frailty prevalence and associated service use and costs will continue to rise in the future. Scenario analysis indicates reduction of incidence and slowing of progression, particularly before the age of 65, has potential to substantially reduce future service use and costs, but reducing unplanned admissions in frail older people has a more modest impact. Study outputs will be collated into a commissioning toolkit, comprising guidance on drivers of frailty-related demand and simulation model outputs.

Study registration

This study is registered as NCT04139278 www.clinicaltrials.gov.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/116/43) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 44. See the NIHR Funding and Awards website for further award information.

Intake of vegetables and fruits at midlife and the risk of physical frailty in later life

OBJECTIVES

Our study evaluated the independent and overall associations of vegetable and fruit consumption at midlife with the likelihood of physical frailty in later life. We also investigated whether specific nutrients in these foods could have accounted for these associations, if present.

DESIGN

Prospective cohort study.

SETTING

A population-based cohort of Chinese adults followed over a period of 20 years in Singapore.

PARTICIPANTS

We used data from 11,959 subjects who participated in the baseline (1993-1998) and follow-up 3 (2014-2017) interviews of the Singapore Chinese Health Study.

MEASUREMENTS

At baseline, dietary intake was evaluated using a validated food frequency questionnaire. During the follow-up 3 visits, physical frailty was assessed using a modified Cardiovascular Health Study phenotype that included weakness, slowness, exhaustion and weight loss. Multivariable logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI) for the associations with physical frailty.

RESULTS

Participants had mean ages of 52 years at baseline, and 72 years at follow-up 3. Baseline intake of vegetables, but not of fruits, showed a dose-dependent inverse relationship with physical frailty at follow-up 3 (Ptrend = 0.001). Compared to participants in the lowest quintile of vegetable intake, those in the highest quintile had reduced odds of frailty [OR (95% CI): 0.73 (0.60-0.89)]. Among the components of physical frailty, vegetable intake had the strongest inverse association with weakness defined by handgrip strength [OR (95% CI) between extreme quintiles: 0.62 (0.52-0.73); Ptrend < 0.001]. In models that were individually adjusted for nutrients, the vegetable-frailty association was attenuated and no longer statistically significant after adjusting for the intake of β-carotene, lutein, folate, α-carotene, and isothiocyanates.

CONCLUSION

Increased midlife intake of vegetables was associated with reduced odds of physical frailty in later life, and the intake of β-carotene, lutein, folate, α-carotene, and isothiocyanates could have accounted for this association.

Social support and frailty progression in community-dwelling older adults

Objectives

Despite the growing evidence regarding the influence of social factors on frailty in older adults, the effect of social support remains unclear. This study aims to assess the association between social support and frailty progression (transition and incidence) in a sample of community-dwelling older adults.

Methods

Using a cohort study design, 1,059 older adults from the Berlin Initiative Study were followed up for 2.1 years. Multinomial and logistic regression analyses were performed to assess the association of social support using Oslo Social Support Scale-3 with frailty transition and incidence, respectively. Gender differences were explored using stratified analyses.

Results

At baseline, frailty prevalence in the study population [mean (SD) age 84.3 (5.6) years; 55.8% women] reached 33.1% with 47.0, 29.4 and 23.6% of the participants reporting moderate, strong and poor social support, respectively. Over the follow-up period, social support was not significantly associated with the frailty transition categories in the adjusted model. Conversely, the adjusted logistic regression analysis showed that participants with poor social support had twice the odds of becoming frail compared to those with strong social support (OR 2.07; 95% CI 1.08-3.95). Gender-stratified analyses showed comparable estimates to the main analysis but were statistically non-significant.

Discussion

Our study results underpin the role of social factors in frailty incidence and highlight social support as a potential target for frailty-preventing interventions in older adults. Therefore, it is important to adopt a biopsychosocial model rather than a purely biomedical model to understand and holistically improve the health of community-dwelling older adults.

Association of frailty with mortality in cancer survivors: results from NHANES 1999-2018

Cancer survivors are vulnerable to frailty. While few studies have focused on the association of frailty with mortality risk among cancer survivors, the current study aimed to reveal this association. In this cohort study, 4723 cancer survivors were enrolled from the National Health and Nutrition Examination Surveys (NHANES, 1999-2018). Frailty status was quantified using the 53-item frailty index. Death outcomes were linked to National Death Index mortality data (as of December 31, 2019). Cox proportional hazard models were used to estimate HRs (95% CIs). The median (IQR) frailty score was 0.190 (0.132, 0.277). During the median follow-up of 6.7 years, 1775 all-cause deaths (including 581 cancer deaths and 385 cardiac deaths) were documented. Compared to the lowest tertile of frailty scores, the adjusted HRs (95% CIs) for the highest tertile were 2.698 (2.224, 3.272) for all-cause mortality (P trend < 0.001), 2.145 (1.547, 2.973) for cancer mortality (P trend < 0.001), and 3.735 (2.231, 6.251) for cardiac mortality (P trend < 0.001). Moreover, a positive dose‒response association between the frailty score and mortality risk was determined. Each per-unit increase in the frailty score (natural logarithm transformed) was found to increase all-cause mortality by 159% (P < 0.001), cancer mortality by 103% (P < 0.001), and cardiac mortality by 256% (P < 0.001). A consistent result was shown when stratifying by age, sex, race, body mass index, and type of cancer. This study suggested that the frailty index was positively associated with all-cause mortality and cause-specific mortality (including cancer and cardiac deaths) among cancer survivors.

The association of technology acceptance and physical activity on frailty in older adults during the COVID-19 pandemic period

BACKGROUND

Physical activity was known to be the protective factor against frailty. Technology acceptance is associated with behavioural intention to technology usage. Technology has been effective in promoting healthy behaviour of physical activity. The purposes of this study were to examine the association between physical activity and technology acceptance with frailty and examine the moderation effect of technology acceptance on physical activity and frailty. We hypothesize that 1) physical activity and technology acceptance are associated with frailty, and 2) technology acceptance moderates the association of physical activity with frailty.

METHODS

This study employed a cross-sectional design and was conducted in the community settings of Hong Kong in 2021. Eligible participants were old people aged ≥60 and were community-dwelling. Key variables included physical activity measured by Rapid Assessment of Physical Activity (RAPA), social network measured by Lubben Social Network Scale-Six items (LSNS-6); depressive symptoms measured by Patient Health Questionnaire-Nine items (PHQ-9), technology acceptance measured by Senior Technology Acceptance Model-14 items (STAM-14) and frailty measured by Fatigue, Resistance, Ambulation, Illnesses, & Loss of Weight scale (FRAIL). Ordinal logistic regression was employed to test the hypotheses. The moderation effect was examined by introducing an interaction term formed by the multiplication of an independent variable (i.e., physical activity) and a moderating variable (i.e., technology acceptance).

RESULTS

This study recruited 380 eligible participants with a mean age of 66.5 years. Technology acceptance (Beta = - 0.031, p < 0.001, Pseudo-R2 = 0.087) and physical activity (Beta = - 0.182, p = 0.003, Pseudo-R2 = 0.027) were associated with frailty in the unadjusted models. Technology acceptance (Beta = - 0.066, p < 0.001) and physical activity (Beta = - 1.192, p < 0.001) were also associated with frailty in the fully adjusted model (Pseudo-R2 = 0.352). Interaction term formed by the multiplication of technology acceptance and physical activity (Beta = 0.012, p = 0.001) was associated with frailty. Physical activity was significantly associated with frailty in the lower technology acceptance subgroup (Beta = - 0.313, p = 0.002) in the subgroup analysis. However, in the subgroup of higher technology acceptance, the association of physical activity (Beta = 0.104, p = 408) on frailty became positive but not significant.

CONCLUSIONS

This study showed that physical activity and technology acceptance were associated with frailty, and technology acceptance moderated the association of physical activity with frailty. This study recommends engaging older adults in physical activity to combat frailty preferentially in those with a lower level of technology acceptance.

What If the Clinical and Older Adults' Perspectives about Frailty Converge? A Call for a Mixed Conceptual Model of Frailty: A Traditional Literature Review

Existing frailty models have enhanced research and practice; however, none of the models accounts for the perspective of older adults upon defining and operationalizing frailty. We aim to propose a mixed conceptual model that builds on the integral model while accounting for older adults' perceptions and lived experiences of frailty. We conducted a traditional literature review to address frailty attributes, risk factors, consequences, perceptions, and lived experiences of older adults with frailty. Frailty attributes are vulnerability/susceptibility, aging, dynamic, complex, physical, psychological, and social. Frailty perceptions and lived experience themes/subthemes are refusing frailty labeling, being labeled "by others" as compared to "self-labeling", from the perception of being frail towards acting as being frail, positive self-image, skepticism about frailty screening, communicating the term "frail", and negative and positive impacts and experiences of frailty. Frailty risk factors are classified into socio-demographic, biological, physical, psychological/cognitive, behavioral, and situational/environmental factors. The consequences of frailty affect the individual, the caregiver/family, the healthcare sector, and society. The mixed conceptual model of frailty consists of interacting risk factors, interacting attributes surrounded by the older adult's perception and lived experience, and interacting consequences at multiple levels. The mixed conceptual model provides a lens to qualify frailty in addition to quantifying it.

Transitions in robust and prefrail octogenarians after 1 year: the influence of activities of daily living, social participation, and psychological resilience on the frailty state

BACKGROUND

Knowledge opportunities lie ahead as everyday activities, social participation, and psychological resilience might be important predictors for frailty state transitioning in the oldest old. Therefore, this article aims to examine whether changes in basic-, instrumental-, advanced- activities of daily living (b-, i-, a-ADLs), social participation, and psychological resilience predict both a transition from robustness to prefrailty or frailty and vice versa among community-dwelling octogenarians over a follow-up period of one year.

METHODS

To evaluate worsened and improved frailty transitions after one year in 322 octogenarians (Mage = 83.04 ± 2.78), the variables sex, ADLs (b-ADL-DI, i-ADL-DI, a-ADL-DI as baseline and as difference after 6 months values), the CD-RISC (Connor-Davidson Resilience Scale, as baseline and as difference after 6 months), the social participation variables (total participation score, being a member, total number of memberships, level of social participation, being a board member, volunteering, and formal participation as baseline and as difference after 6 months values), were included in a logistic regression analysis.

RESULTS

Limitations in a-ADLs at baseline (OR: 1.048, 95% confidence interval, 1.010-1.090) and an increment of limitations in a-ADLs after 6 months (OR: 1.044, 95% confidence interval, 1.007-1.085) were predictors to shift from robust to a worsened frailty state after one year follow-up. Additionally, being a woman (OR: 3.682, 95% confidence interval, 1.379-10.139) and social participation, specifically becoming a board member in 6 months (OR: 4.343, 95% confidence interval, 1.082-16.347), were protectors of robustness and thus related to an improved frailty transition after one year.

CONCLUSIONS

Encouraging healthy lifestyle behaviors to help the maintenance of ADLs, possibly leading to more social participation, could be promising in the prevention of frailty.

Associations between multimorbidity and frailty transitions among older Americans

BACKGROUND

The associations of multimorbidity patterns with transitions between frailty states remain unclear in older individuals.

METHODS

We used data from the National Health and Aging Trends Study 2011-2019. Frailty was measured annually using the Fried frailty phenotype. Multimorbidity patterns at baseline were identified using latent class analysis based on 14 chronic conditions. We used the semi-Markov multi-state model to investigate the influences of multimorbidity characterized by condition counts and patterns on subsequent frailty transitions over follow-ups.

RESULTS

Among 9450 participants aged ≥65 years at baseline, 34.8% were non-frail, 48.1% were pre-frail and 17.0% were frail. Over a median follow-up of 4.0 years, 16 880 frailty transitions were observed, with 10 527 worsening and 6353 improving. For 7675 participants with multimorbidity, four multimorbidity patterns were identified: osteoarticular pattern (62.4%), neuropsychiatric-sensory pattern (17.2%), cardiometabolic pattern (10.3%) and complex multimorbidity pattern (10.1%). Compared with no disease, multimorbidity was significantly associated with an increased risk of worsening transitions, including from non-frail to pre-frail (hazard ratio [HR] = 1.35; 95% confidence interval [CI] = 1.21-1.52), from non-frail to frail (HR = 1.68; 95% CI = 1.04-2.73), from pre-frail to frail (HR = 2.19; 95% CI = 1.66-2.90) and from pre-frail to death (HR = 1.64; 95% CI = 1.11-2.41). Compared with the osteoarticular pattern, neuropsychiatric-sensory, cardiometabolic and complex multimorbidity patterns had a significantly higher risk of worsening frailty (all P < 0.05).

CONCLUSIONS

Multimorbidity was associated with dynamic transitions between frailty states and death among older American adults, and the associations varied across multimorbidity patterns. The findings could offer significant implications for public health policymakers in planning interventions and healthcare resources. They also might inform clinicians regarding providing targeted clinical treatment and health management based on multimorbidity patterns of older people.

The impact of covid-19 lockdown on the Quality of life, meaningful activities, and frailty in community-dwelling octogenarians: A study in Belgium

OBJECTIVES

To investigate the impact of COVID-19 lockdown on quality of life (QoL), meaningful daily activities, and (pre)frailty in community-dwelling octogenarians.

METHODS

Cross-sectional design with bivariate and multiple linear regression modeling using a stepwise approach examining the level of QoL during the COVID-19 lockdown in a group of 215 community-dwelling octogenarians (M_age = 86.49 ± 3.02). A comprehensive set of biopsychosocial variables (FRAIL scale, general health, engagement in meaningful activities survey, questions on loneliness, and feelings) were used as explaining variables.

RESULTS

Particularly, a decrease in daily activities, social activities, and an increase in free times activities were observed, but the decrease in QoL could be explained by the meaningfulness in activities, together with experiencing emptiness in life, taking ≥ 4 medications a day and feeling down or depressed.

CONCLUSIONS

We tried to understand which components contribute to and might affect a person's QoL caused by restrictions imposed by the governance and its influence on the lives of the community-dwelling octogenarians. As such, this output could be a baseline for the development of minimally impacting countermeasures during future lockdowns.

CLINICAL IMPLICATIONS

Studying lifestyle changes and thus also variables related to QoL during a pandemic, may support policymakers and practitioners to develop relevant interventions.

Association of longitudinal repeated measurements of frailty index with mortality: Cohort study among community-dwelling older adults

BACKGROUND

Frailty indices (FIs), defined by accumulation of health deficits, have been shown to be strongly related to mortality in older adults. However, previous studies mostly relied on FI measurement at a single point of time. We aimed to investigate the association of frailty with mortality according to longitudinal repeated measurements of FI in a large population-based cohort study in Germany.

METHODS

Among 9912 men and women aged 50-75 years living in Saarland, Germany and recruited in the ESTHER study in 2000-2002, a FI based on 30 deficits was determined at baseline, 2-, 5-, 8-, and 11-year follow-up. Hazard ratios (HRs) were calculated to assess the associations of FI with all-cause mortality and cause-specific mortality during 14 years of follow-up using Cox proportional hazards models that included FI as a time-varying covariate.

FINDINGS

During the 14-year follow-up, a total of 2483 deaths were observed, of which 859 and 863 were due to cancer and cardiovascular diseases (CVD), respectively. The time-varying FI showed consistently strong associations with mortality throughout 14 years of follow-up, with HRs (95% confidence intervals) for frail (FI≥ 0·35) versus non-frail (FI≤ 0·11) participants of 4·72 (4.05-5.51), 2·55 (1·95-3·34) and 7·52 (5·69-9·94) for all-cause, cancer, and CVD mortality, respectively. Gradually decreasing associations with increasing length of follow-up would have been obtained by using baseline FI only.

INTERPRETATION

Longitudinal repeated measures of FI show strong, consistent associations with mortality, especially CVD mortality, throughout extended periods of follow-up among community-dwelling older adults.

FUNDING

The ESTHER study was funded by grants from the Baden-Württemberg state Ministry of Science, Research and Arts (Stuttgart, Germany), the Federal Ministry of Education and Research (Berlin, Germany), the Federal Ministry of Family Affairs, Senior Citizens, Women and Youth (Berlin, Germany), and the Saarland State Ministry of Health, Social Affairs, Women and the Family (Saarbrücken, Germany).