Prefrailty in older adults: A concept analysis

Does the association between adiposity measures and pre-frailty among older adults vary by social position? Findings from the Tromsø study 2015/2016

INTRODUCTION

Pre-frailty provides an ideal opportunity to prevent physical frailty and promote healthy ageing. Excess adiposity has been associated with an increased risk of pre-frailty, but limited studies have explored whether the association between adiposity measures and pre-frailty varies by social position.

METHODS

We used data from the seventh survey of the Tromsø Study (Tromsø7) conducted in 2015-2016. Our primary sample consisted of 2,945 women and 2,794 men aged ≥ 65 years. Pre-frailty was defined as the presence of one or two of the five frailty components: low grip strength, slow walking speed, exhaustion, unintentional weight loss and low physical activity. Adiposity was defined by body mass index (BMI), waist circumference (WC), fat mass index (FMI) and visceral adipose tissue (VAT) mass. Education and subjective social position were used as measures of social position. Poisson regression with robust variance was used to assess the association between adiposity measures and pre-frailty, and the interaction term between adiposity measures and social position measures were utilised to explore whether the association varied by social position.

RESULTS

In our sample, 28.7% of women and 25.5% of men were pre-frail. We found sub-multiplicative interaction of BMI-defined obesity with education in women and subjective social position in men with respect to development of pre-frailty. No other adiposity measures showed significant variation by education or subjective social position. Regardless of the levels of education or subjective social position, participants with excess adiposity (high BMI, high WC, high FMI and high VAT mass) had a higher risk of pre-frailty compared to those with low adiposity.

CONCLUSION

We consistently observed that women and men with excess adiposity had a greater risk of pre-frailty than those with low adiposity, with only slight variation by social position. These results emphasize the importance of preventing excess adiposity to promote healthy ageing and prevent frailty among all older adults across social strata.

A Mixed Methods Feasibility Study of Machine-Based Resistance Training With Prefrail Older Adults in Residential Care: The Keeping Active in Residential Elderly Trial II

Physical activity is an effective, proactive intervention to reduce or reverse frailty and functional decline. However, uncertainty exists about the feasibility and impact of resistance training on multidimensional health in prefrail older adults in residential care. This mixed methods feasibility study assessed practicability with limited efficacy testing on health and functional outcomes. Eleven prefrail older adults participated in a 6-week progressive resistance training protocol three times per week. The intervention and measures were found to be appropriate and acceptable by those who completed the trial, with participants self-reporting improved well-being, mood, and function. Analysis identified several barriers to recruitment, including prior commitments, seasonal impact, and session timing, and offered potential solutions with further recommendations for program refinement prior to a definitive randomized controlled trial. These findings add to our understanding of prefrail older adults' preferences regarding participation in physical activity research and the perceived benefits of resistance training. This trial was registered with ClinicalTrials.gov: NCT03141879.

Disease activity at baseline is an independent predictor of frailty at one year in pre-frail patients with rheumatoid arthritis; a multicenter retrospective observational study

OBJECTIVES

To investigate factors predicting frailty for one year in pre-frail patients with rheumatoid arthritis (RA).

METHOD

A total of 298 RA patients who were pre-frail in 2020 were evaluated in this structured, retrospective observational study. Of the 298 patients, 42 who were frail and 256 who were not in 2021 were assigned to the frailty and non-frailty groups, respectively. After comparing characteristics of both groups using univariate analysis, predictive factors of frailty were assessed by logistic regression analysis. The proportion of frail patients in 2021 by DAS28-ESR level in 2020 was examined by the Cochran-Armitage trend test and chi-squared test. After dividing pre-frail patients into those with DAS28-ESR ≥3.2 and DAS28-ESR <3.2 in 2020, one-year change in DAS28-ESR in the frailty and non-frailty groups for both subgroups were compared by the paired t-test.

RESULTS

The frailty group was older (mean: 71.0 vs. 65.4 years) and had a higher DAS28-ESR (mean: 3.22 vs. 2.70) than the non-frailty group. DAS28-ESR was identified as a predictive factor for frailty (OR: 1.49). Among patients with DAS28-ESR ≥3.2 in 2020, DAS28-ESR improved in the non-frailty group in 2021 (mean: 3.97 in 2020 vs. 3.13 in 2021) but did not in the frailty group (3.97 in 2020 vs. 3.81 in 2021). Among those with DAS28-ESR <3.2 in 2020, DAS28-ESR was unchanged in the non-frailty group in 2021 (2.15 in 2020 vs. 2.23 in 2021) but increased in the frailty group (2.53 in 2020 vs. 3.23 in 2021).

CONCLUSIONS

Disease activity at baseline is an independent predictor of frailty one year later in pre-frail patients with RA.

Prevalence of frailty and its association with clinical outcomes in myeloproliferative neoplasms: a population-based study

Clinical implications of frailty in myeloproliferative neoplasms (MPN), including essential thrombocythemia (ET), polycythemia vera (PV), and myelofibrosis (MF), are unknown. In this population-based study, all incident cases of MPN from the Ontario cancer registry between 2004 and 2019 (N = 10 336; ET = 5108; PV = 3843; MF = 1385) and their matched controls (for age, sex, residence, and income) in a 1:4 ratio were included. Baseline frailty measured using the Johns Hopkins Adjusted Clinical Groups frailty indicator and McIsaac frailty index (mFI), categorized as fit, prefrail, or frail if mFI <0.10, 0.11 to 0.20, >0.20), was significantly higher in ET, PV, and MF compared with matched controls (standardized mean difference of 0.27, 0.27, and 0.28). Over 23%, 20%, and 34% of patients with ET, PV, and MF were frail or prefrail despite a younger age (<65 years) or minimal comorbidities. In Cox proportional regression, frailty was independently associated with worse overall survival (OS) after adjusting for age, sex, and comorbidities compared with mFI-fit patients. The hazard ratios (95% confidence interval) for OS for mFI-prefrail and mFI-frail patients were: 1.6 (1.3-1.9) and 3.6 (2.9-4.4) in ET, 1.3 (1.1-1.5) and 2.7 (2.1-3.4) in PV, and 1.2 (1.0-1.5) and 2.0 (1.5-2.7) in MF. Patients with MPN have a substantially higher prevalence of frailty compared with matched controls, which is associated with reduced OS, independent of age or comorbidities.

Prevalence and factors associated with frailty and pre-frailty in the older adults in China: a national cross-sectional study

Objective

Frailty increases poor clinical outcomes in older adults, the aim of this study was to investigate the prevalence and factors associated with frailty and pre-frailty in older adults in China.

Research design and methods

Data were obtained from the Sample Survey of the Aged Population in Urban and Rural China in 2015, which was a cross-sectional study involving a nationally representative sample of older adults aged 60 years or older from 31 provinces/autonomous regions/municipalities in mainland China. The frailty index (FI) based on 33 potential deficits was used to classify individuals as robust (FI < 0.12), pre-frail (FI ≧0.12 and <0.25) and frail (FI ≥0.25).

Results

A total of 208,386 older people were included in the study, and the age-sex standardised prevalence of frailty and pre-frailty among older adults in China was 9.5% (95% CI 9.4-9.7) and 46.1% (45.9-46.3) respectively. The prevalence of frailty and pre-frailty was higher in female than in male older adults, higher in rural than in urban older adults, and higher in northern China than in southern China. The multinomial analysis revealed similar risk factors for frailty and pre-frailty, including increased age, being female, living in a rural area, low educational attainment, poor marital status, living alone, difficult financial status, poor access to medical reimbursement, and living in northern China.

Conclusion

Frailty and pre-frailty are very common among older adults in China and differ significantly between southern and northern China, men and women, and rural and urban areas. Appropriate public health prevention strategies should be developed based on identified risk factors in frail and pre-frail populations. The management of frailty and pre-frailty should be optimised according to regional and gender differences in prevalence and associated factors, such as strengthening the integrated management of chronic diseases, increasing reimbursement rates for medical costs, and focusing on vulnerable groups such as the disabled, economically disadvantaged, living alone and those with low literacy levels, in order to reduce the burden of frailty among older adults in China.

Association of Prefrailty and Frailty With All-Cause Mortality, Acute Exacerbation, and Hospitalization in Patients With Chronic Obstructive Pulmonary Disease: A Meta-Analysis

OBJECTIVE

To evaluate the impact of prefrailty and frailty on all-cause mortality, acute exacerbation, and all-cause hospitalization in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

Meta-analysis.

SETTING AND PARTICIPANTS

Two authors independently searched PubMed, Web of Science, and Embase databases until December 27, 2022，to identify studies that reported the predictive value of prefrailty and frailty in COPD patients.

MEASUREMENTS

All-cause mortality, acute exacerbation, and all-cause hospitalization.

RESULTS

Ten studies reporting on 11 articles enrolling 13,203 patients with COPD were included. The prevalence of frailty ranged from 6.0% to 51%. When compared with nonfrailty, the pooled adjusted hazard ratio (HR) of all-cause mortality was 1.48 (95% CI 0.92-2.40) for prefrailty and 2.64 (95% CI 1.74-4.02) for frailty, respectively. The pooled adjusted odds ratio (OR) of all-cause hospitalization was 1.35 (95% CI 1.05-1.74) for prefrailty and 1.65 (95% CI 1.05-2.61) for frailty. In addition, frailty significantly predicted all acute exacerbation (OR 2.20, 95% CI 1.26-3.81) but not moderate to severe acute exacerbation (OR 1.42, 95% CI 0.94-2.17) in patients with stable COPD. However, the pooled results of all-cause hospitalization were not reliable in leave-1-out sensitivity analyses.

CONCLUSIONS AND IMPLICATIONS

Frailty significantly predicts all-cause mortality in patients with COPD, even after adjustment for common confounding factors. Assessment of frail status in COPD patients may improve secondary prevention and allow early intervention. However, future studies are warranted to validate the impact of frailty defined by a standardized definition of frailty on acute exacerbation and all-cause hospitalization.

Effects of exercise interventions on physical and psychological outcomes in frail older adults: Protocol for an overview of systematic reviews

AIMS

To systematically summarize the existing evidence regarding the effects of exercise interventions on physical and psychological outcomes in frail older adults and appraise the quality and strength of the evidence.

DESIGN

An overview protocol.

METHODS

A literature search of PubMed, Embase, Web of Science, CINAHL and Cochrane Database of Systematic Reviews will be conducted to identify relevant systematic reviews with or without meta-analysis on exercise interventions for frail older adults. Two independent reviewers will select articles, extract data and appraise the quality of included reviews. Physical and psychological outcomes will be synthesized using narrative summaries. The methodological quality of included reviews and the quality of evidence will also be assessed.

RESULTS

This overview will present the evidence on the effects of exercise interventions on physical and psychological outcomes for frail older adults, contributing to the implementation of exercise interventions to improve health outcomes for this population.

Dual-Energy X-Ray Absorptiometry Derived Adiposity Measures and Pre-Frailty/Frailty among Norwegian Adults: The Tromsø Study 2007-2015

OBJECTIVES

Aging is associated with changes in body composition. Excess adiposity among older adults has been linked with metabolic syndromes and aggravated age-associated decline in physical functioning. Few longitudinal studies have explored the association between dual-energy X-ray absorptiometry (DXA)-derived total as well as central adiposity measures and frailty. We examined the association of DXA-derived total and central adiposity with pre-frailty/frailty among Norwegian adults after 8 years of follow-up.

DESIGN

Prospective observational study.

SETTING

Community-dwelling adults from Tromsø, Norway.

MEASUREMENTS

Adiposity was defined by fat mass index (FMI) and visceral adipose tissue (VAT) mass assessed using DXA measures. Frailty status was assessed by low grip strength, slow walking speed, exhaustion, unintentional weight loss and low physical activity level. Pre-frail and frail participants at baseline were excluded. Sex-stratified multivariable logistic regression models were used to investigate the association.

RESULTS

Participants comprised 234 women (mean age 68 years) and 146 men (mean age 69 years) attending the population-based Tromsø Study in 2007-2008 (Tromsø6) and 2015-2016 (Tromsø7). At the end of follow-up, 25.6% of the women and 27.4% of the men were pre-frail/frail. Compared with women in the lowest tertiles, those in the highest tertile of baseline FMI (odds ratio [OR] 4.42, 95% confidence interval [CI] 1.88-10.35) and VAT mass (OR 2.47, 95% CI 1.10-5.50), respectively had higher odds for pre-frailty/frailty at follow-up.

CONCLUSION

We found a higher likelihood of pre-frailty/frailty in later years among women with general and central adiposity in adulthood, highlighting the importance of preventing excess adiposity for healthy aging.

Validation and reliability of the Care Vulnerability Index: A study by interrater agreement and test-retest method

Aim

The aim of this study is to determine the validity and reliability of the Care Vulnerability Index (CVI) as a tool to estimate the need and competence of care.

Design

A cross‐sectional survey including a longitudinal component.

Methods

Content validity ratio (CVR) was calculated by interrater agreement of a group of 11 experts in two rounds. The test–retest analysis was measured in an urban population of Colombia with 96 participants through two statistical tests: Pearson's correlation coefficient and the difference in means.

Results

Care Vulnerability Index turned out to be valid with a CVR of 0.879. Reliability by Pearson correlation between test–retest was 0.912 (CI95: 0.872–0.941; p‐value <.01) and there was no significant mean difference between test and retest in global score and in clustered groups of variables. Validating CVI will make it possible to prioritize healthcare resources in the population and identify people susceptible to care problems.

Does psychological resilience mediate the relation between daily functioning and prefrailty status?

OBJECTIVES

Understanding of prefrailty's relationship with limitations in activities of daily living (ADLs) moderated by psychological resilience is needed, as resilience might support ADLs' maintenance and thus protect against frailty. Therefore, this study aims to analyze the influence of psychological resilience (using the Connor-Davidson Resilience Scale; CD-RISC) on the relation between ADLs and frailty status of older individuals (i.e. prefrail versus robust).

DESIGN

Cross-sectional design.

SETTING

UZ Brussels, Belgium.

PARTICIPANTS

Robust (Fried 0/4;n = 214; Age = 82.3 ± 2.1yrs) and prefrail (Fried 1-2/4; n = 191; Age = 83.8 ±3.2yrs) community-dwelling older individuals were included.

MEASUREMENTS

Frailty scores were obtained from weight loss, exhaustion, gait speed, and grip strength. A total Disability Index (DI) expressed dependency for basic (b-), instrumental (i-), and advanced (a-)ADLs. Mediation was investigated by estimating direct and indirect effects of all levels of ADLs and CD-RISC total score on prefrailty/robustness using a stepwise multiple regression approach.

RESULTS

Prefrailty/robustness significantly correlated with a-ADL-DI (point-biserial correlation (rpb) = 0.098; p<0.05). Adjusted for age and gender, the a-ADL-DI (p<0.05) had a significant protective direct effect against prefrailty. No effects were found with the CD-RISC total score.

CONCLUSIONS

Less limitation in a-ADLs is a directly correlated factor of prefrailty and might represent a higher likelihood of robustness.

Frailty state transitions among non-frail and vulnerable older adults: Does mobility performance really matter?

We assessed the predictors of becoming frail between non-frail and vulnerable community-dwelling older adults in a retrospective cohort study with adults (n=346) aged 60 years or older recruited from primary healthcare centers. Edmonton Frailty Scale assessed frailty status, and Kaplan-Meier estimated the frailty-free probability and compared it between groups. Cox regression models explored predictors of becoming frail. At baseline, there were 32.3% individuals classified as Frail according to the EFS, whereas 32.4% were vulnerable and 35.3% non-frail. We observed 82 incident cases of frailty, 65.8% among those classified as vulnerable and 37.8% in the non-frail group (p < 0.05). Female sex, years of education, and an overall score of < 45 on the Berg Balance Scale were the only independent predictors of becoming frail. Although frailty is not only correlated with mobility, static and dynamic balancing abilities appear to have the same impact as a vulnerable state to becoming frail.

Screening prefrailty in Japanese community-dwelling older adults with daily gait speed and number of steps via tri-axial accelerometers

Prefrailty is an intermediate stage between non-frailty and frailty. It is associated with an increased risk of progression to frailty, which makes it important to screen older adults for prefrailty at an early stage. This study verified whether daily gait speed and number of steps measured using a tri-axial accelerometer could be used to identify prefrailty. In total, 1692 Japanese community-dwelling older adults were divided into robust (n = 1032) and prefrail (n = 660) groups based on the Kihon Checklist, which is a self-administered questionnaire. Both daily gait speed and number of steps were measured for two weeks using tri-axial accelerometers. We also calculated the area under the ROC curve and the cut-off values for these parameters. Our results showed that the cut-off value for daily gait speed was 106.3 cm/s, while that for number of steps was 6342.2. In addition, we found that the combined assessment of both cut-off values was a more effective way to screen older adults with prefrailty status compared to either parameter alone. This is also considered an effective way to reduce national expenditures for daily care assistance.

Impacts of Frailty on Prognosis in Lung Cancer Patients: A Systematic Review and Meta-Analysis

Background: Frailty is a common geriatric syndrome and is described as a limited ability to compensate and recover from stressors. Lung cancer is largely diagnosed in old age, when frailty is common and might have predictive value on prognosis. Therefore, we performed a systematic review to evaluate the prognostic role of frailty in lung cancer.

Methods: The online PubMed, Web of Science, CNKI and Wanfang literature databases were searched to identify all related articles that reported the predictive value of frailty for mortality and therapeutic toxicity. Review Manager 5.3 was used to analyze results by standard meta-analysis methodology.

Results: Seven studies were included in this review, and only six studies with 2,359 patients were enrolled in meta-analysis. Patients in two studies received chemotherapy, two studies radiotherapy, two studies surgery, one study not reported. Compared to non-frail patients, frail patients had a higher risk of overall mortality [Hazard Ratio (HR) = 1.57, 95% confidence interval (CI), 1.32–1.87], and therapeutic toxicity [Odds Ratio (OR) = 2.60, 95% CI, 0.82–8.24]. Prefrail patients also showed higher overall mortality and therapeutic toxicity than non-frail patients (HR = 1.20, 95% CI, 1.05–1.38; OR = 1.72, 95% CI, 1.18–2.51, respectively).

Conclusions: Frailty is a powerful predictor of overall mortality and therapeutic toxicity in lung cancer patients.

Resistance exercise training at different loads in frail and healthy older adults: A randomised feasibility trial

Objectives

This trial aimed to determine the feasibility of recruitment, retention, adherence, and safety of a resistance training (RT) intervention to skeletal muscle failure in both frail and non-frail older adults.

Design

An 8-week randomised feasibility trial.

Setting and participants

Older adults, with and without frailty, recruited from both clinics and community.

Methods

Recruitment was based on the number of participants enrolled from those provided with a Patient Information Sheet (PIS). Retention was based on the number of participants who completed the trial. Adherence was based on the number of RT sessions attended out of 16. Outcomes included frailty (Fried criteria), muscle strength (maximal voluntary contraction), functional abilities (Short Physical Performance battery), quality of life (EQ-5D-5L), activities of daily living (LIADL) and safety (diary).

Results

Recruitment target (n = 60) was achieved within 15 months, 58 were randomised to high (n = 30) or low repetition-load (n = 28) groups. Mean age of participants was 72 years (range 65–93). Adherence and retention rate for the RT intervention was ≥70%. There was one serious adverse experience due to the RT intervention. There were no differences (P > 0.05) in effects of RT on outcome variables between low and high repetition-load groups.

Conclusions and implications

Recruitment of frail people was challenging. Older adults performing supervised RT to skeletal muscle failure was feasible and safe, with appropriate caution, and the repetition-load did not appear to influence its efficacy. Future research into the effectiveness of this simplified model of RT is warranted.

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Resistance exercise is the most effective way to increase muscle mass.

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This is particularly important in older adults.

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Recruitment of older adults, particularly with frailty, is challenging.

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We found recruitment of older adults feasible, but less so for those with frailty.

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The load for exercise did not appear to influence efficacy of exercise.

Adding high-sensitivity C-reactive protein to frailty assessment to predict mortality and cardiovascular events in elderly inpatients with cardiovascular disease

OBJECTIVE

Chronic inflammation is associated with major adverse cardiovascular events (MACEs), mortality, and frailty. Our aim was to add high-sensitivity C-reactive protein (hsCRP) to the frailty assessment to predict its association with prognosis of older adults with cardiovascular disease (CVD).

METHODS

A comprehensive geriatric assessment was conducted at baseline in 720 in-patients aged ≥65 years with CVD. We divided the population into frailty and non-frailty groups according to the Fried phenotype, and hsCRP was further combined with frailty to stratify all patients into c-frailty and non-c-frailty groups. Predictive validity was tested using Cox proportional hazards regression model analysis and the discriminative ability was evaluated by receiver operating characteristic (ROC) curves.

RESULTS

Of all the subjects enrolled, 51.0% were male and the mean age was 75.32 ± 6.52 years. The all-cause death and MACE rate was 6.4% at the 1-year follow-up. Frailty and c-frailty were independent predictors of all-cause death and MACE (hazard ratio [HR]: 2.55, 95% confidence interval [CI]: 1.35-4.83, p = 0.004; HR: 3.67, 95% CI: 1.83-7.39, p < 0.001). Adding hsCRP to the frailty model resulted in a significant increase in the area under the ROC curve from 0.74 (95% CI: 0.70-0.77) to 0.77 (95% CI: 0.71-0.84) (p = 0.0132) and a net reclassification index of 7.9% (95% CI: 1.96%-12.56%, p = 0.012).

CONCLUSION

Adding hsCRP to the frailty assessment is helpful to identify a subgroup of older CVD patients with a higher risk of death and MACE over a period of 1 year.

TRIAL REGISTRATION

ChiCTR1800017204; date of registration: 07/18/2018. URL: http://www.chictr.org.cn/showproj.aspx?proj=28931.