Ability of Self-Reported Frailty Components to Predict Incident Disability, Falls, and All-Cause Mortality: Results From a Population-Based Study of Older British Men

Long-term changes in frailty and incident type 2 diabetes: A prospective cohort study based on the UK Biobank

AIMS

To estimate the association between long-term changes in frailty and the risk of incident type 2 diabetes (T2DM) and to evaluate the effect of preventing the worsening of frailty on the risk of T2DM.

METHODS

We included 348 205 participants free of baseline T2DM and with frailty phenotype (FP) data from the UK Biobank; among them, 36 175 had at least one follow-up assessment. According to their FP score, participants were grouped into nonfrailty, prefrailty and frailty groups. Frailty assessed at baseline and at follow-up was used to derive the trajectory of frailty (ΔFP). Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Compared with those in the nonfrailty group at baseline, the HRs of T2DM for the prefrailty and frailty groups were 1.38 (95% CI 1.33-1.43) and 1.69 (95% CI 1.59-1.79), respectively (both p < 0.001), in the multivariable-adjusted model. During a median follow-up of 5.4 years after the final assessment, data for 472 T2DM patients were recorded. A 1-point increase in the final FP was associated with a 25% (95% CI 1.14-1.38; p < 0.001) increased risk of T2DM. For the trajectory of frailty, each 0.5-point/year increase in ΔFP was associated with a 52% (95% CI 1.18-1.97; p < 0.001) greater risk of T2DM, independent of the FP score at baseline. Compared with those that remained in the nonfrailty group, the greatest risk of T2DM over time was prefrailty aggravation (HR 3.03, 95% CI 2.00-4.58; p < 0.001). Using the frailty index did not materially change the results.

CONCLUSIONS

Long-term changes in frailty were associated with the risk of incident T2DM, irrespective of baseline frailty status. Preventing the worsening of frailty may reduce T2DM risk.

Associations between healthy lifestyle and mortality across different social environments: a study among adults with frailty from the UK Biobank

BACKGROUND

Among people living with frailty, adherence to a healthy lifestyle may be a low-cost and effective strategy to decrease frailty-induced health risks across different social environments.

METHODS

We included 15 594 frail participants at baseline from the UK Biobank study. We used four lifestyle factors to create a composite healthy lifestyle score and 17 social factors to construct a polysocial score. We classified the lifestyle score into two levels (unhealthy and healthy) and the polysocial score into three levels (low, intermediate and high). We used Cox regression to determine the association of each lifestyle factor and lifestyle score with all-cause mortality, respectively. We also examined the associations across polysocial score categories. We evaluated the joint association of the lifestyle score and the categorical polysocial score with all-cause mortality.

RESULTS

During up to 14.41 follow-up years, we documented 3098 all-cause deaths. After multivariable adjustment, we found a significant association between not smoking and adequate physical activity with all-cause mortality across polysocial score categories, respectively. We also found a significant association between a healthy diet and all-cause mortality among frail participants living in an intermediate social environment. A healthy lifestyle was associated with a lower all-cause mortality risk across polysocial score categories, especially among those with a low polysocial score.

CONCLUSIONS

Adherence to a healthy lifestyle, particularly not smoking, adequate physical activity and a healthy diet, may provide a feasible solution to decreasing mortality risk among frail adults across different social environments, especially for those in the socially disadvantaged group.

The association between anticholinergic/sedative burden and physical frailty in people aging with HIV

OBJECTIVE

This study aimed to estimate the strength of the association between anticholinergic/sedative burden and concurrent physical frailty in people aging with HIV.

DESIGN

This cross-sectional analysis examined baseline data from 824 adults with a mean age of 53 enrolled in the Positive Brain Health Now study.

METHODS

Anticholinergic medications were identified using four methods: Anticholinergic Cognitive Burden (ACB) Scale, Anticholinergic Risk Scale (ARS), Anticholinergic Drug Scale (ADS), and the anticholinergic list of the Anticholinergic and Sedative Burden Catalog (ACSBC). Sedatives were identified using the Sedative Load Model (SLM) and the sedative list of the ACSBC. Physical frailty was assessed using a modified Fried Frailty Phenotype (FFP) based on self-report items. Multivariable logistic regression models, adjusted for sociodemographic factors, lifestyle considerations, HIV-related variables, comorbidities, and co-medication use, were used to estimate odds ratios (ORs).

RESULTS

Anticholinergic burden demonstrated associations with frailty across various methods: total anticholinergic burden (OR range: 1.22-1.32; 95% confidence interval (CI) range: 1.03-1.66), sedative burden (OR range: 1.18-1.24; 95% CI range: 1.02-1.45), high anticholinergic burden (OR range: 2.12-2.74; 95% CI range: 1.03-6.19), and high sedative burden (OR range: 1.94-2.18; 95% CI: 1.01-4.34).

CONCLUSION

The anticholinergic and sedative burdens may represent modifiable risk factors for frailty in people aging with HIV. Future studies should evaluate the effects of reducing anticholinergic and sedative burdens on frailty outcomes and explore the prognostic value of diverse scoring methods.

Cross-cultural adaptation of the FRAIL scale for critically ill patients in Spain

AIM

To translate and culturally adapt the FRAIL scale into Spanish and perform a preliminary test of diagnostic accuracy in patients admitted to intensive care units.

DESIGN

Cross-sectional diagnostic study.

METHODS

Five intensive care units (ICU) in Spain were participated. Stage 1: Three native Spanish-speaking bilingual translators familiar with the field of critical care translated the scale from English into Spanish. Stage 2: Three native English-speaking bilingual translators familiar with critical care medicine. Stage 3: Authors of the original scale compared the English original and back-translated versions of the scale. Stage 4: Five nurses with more than 5 years of ICU experience and five critical care physicians assessed the comprehension and relevance of each of the items of the Spanish version in 30 patients of 3 different age ranges (<50, 50-65 and >65 years).

RESULTS

The FRAIL scale was translated and adapted cross-culturally for patients admitted to intensive care units in Spain. The process consisted of four stages: translation, back translation, comparison and pilot test. There was good correspondence between the original scale and the Spanish version in 100% of the items. The participating patients assessed the relevance (content validity) and comprehensibility (face validity) of each of the items of the first Spanish version. The relevance of some of the items scored low when the scale was used in patients younger than 65 years.

CONCLUSIONS

We have cross-culturally adapted the FRAIL scale, originally in English, to Spanish for its use in the critical care medical setting in Spanish-speaking countries.

IMPLICATIONS FOR PROFESSIONALS

Physicians and nurses can apply the new scale to all patients admitted to the intensive care units. Nursing care can be adapted according to frailty, trying to reduce the side effects of admission to these units for the most fragile patients.

REPORTING METHOD

The manuscript's authors have adhered to the EQUATOR guidelines, using the COSMIN reporting guideline for studies on the measurement properties of patient-reported outcome measures.

PATIENT OR PUBLIC CONTRIBUTION

In a pilot clinical study, we applied the first version of the FRAIL-Spain scale to intensive care unit (ICU) patients. Five nurses with more than 5 years of ICU experience and five critical care physicians assessed the relevance (content validity) and comprehensibility (face validity) of the five items of the first Spanish version. Relevance was assessed using a 4-point Likert scale ranging from 1 (no relevance) to 4 (high relevance), and comprehensibility was assessed as poor, acceptable or good. Each health professional applied the scale to three patients (total number of patients = 30) of three different age ranges (<50, 50-65 and >65 years) and recorded the time of application of the scale to each patient. Although the frailty scales were initially created by geriatricians to be applied to the elders, there is little experience with their application in critically ill patients of any age. Therefore, more information is needed to determine the relevance of using this scale in critical care patients. In this pilot study, we considered that nurses and critical care physicians should evaluate frailty using this adapted scale in adult patients admitted to the Intensive Care Units.

Physical and brain frailty in ischaemic stroke or TIA: Shared occurrence and outcomes. A cohort study

BACKGROUND

There is increasing interest in the concept of frailty in stroke, including both physical frailty and imaging-evidence of brain frailty. We aimed to establish the prevalence of brain frailty in stroke survivors as well as the concurrent and predictive validity of various frailty measures against long-term cognitive outcomes.

METHODS

We included consecutively admitted stroke or transient ischaemic attack (TIA) survivors from participating stroke centres. Baseline CT scans were used to generate an overall brain frailty score for each participant. We measured frailty via the Rockwood frailty index, and a Fried frailty screening tool. Presence of major or minor neurocognitive disorder at 18-months following stroke or TIA was established via a multicomponent assessment. Prevalence of brain frailty was established based upon observed percentages within groups defined by frailty status (robust, pre-frail, frail). We assessed the concurrent validity of brain frailty and frailty scales via Spearman's rank correlation. We conducted multivariable logistic regression analyses, controlling for age, sex, baseline education and stroke severity, to evaluate association between each frailty measure and 18-month cognitive impairment.

RESULTS

Three-hundred-forty-one stroke survivors participated. Three-quarters of people who were frail had moderate-severe brain frailty and prevalence increased according to frailty status. Brain frailty was weakly correlated with Rockwood frailty (Rho: 0.336; p < 0.001) and with Fried frailty (Rho: 0.230; p < 0.001). Brain frailty (OR: 1.64, 95% CI = 1.17-2.32), Rockwood frailty (OR: 1.05, 95% CI = 1.02-1.08) and Fried frailty (OR: 1.93, 95% CI = 1.39-2.67) were each independently associated with cognitive impairment at 18 months following stroke.

CONCLUSIONS

There appears to be value in the assessment of both physical and brain frailty in patients with ischaemic stroke and TIA. Both are associated with adverse cognitive outcomes and physical frailty remains important when assessing cognitive outcomes.

Translation and Validation of the Swedish Version of the Tilburg Frailty Indicator

The Tilburg Frailty Indicator (TFI) is a questionnaire with 15 questions designed for screening for frailty in community-dwelling older people. TFI has a multidimensional approach to frailty, including physical, psychological, and social dimensions. The aim of this study was to translate TFI into Swedish and study its psychometric properties in community-dwelling older people with multimorbidity. A cross-sectional study of individuals 75 years and older, with ≥3 diagnoses of the ICD-10 and ≥3 visits to the Emergency Department in the past 18 months. International guidelines for back-translation were followed. Psychometric properties of the TFI were examined by determining the reliability (inter-item correlations, internal consistency, test-retest) and validity (concurrent, construct, structural). A total of 315 participants (57.8% women) were included, and the mean age was 83.3 years. The reliability coefficient KR-20 was 0.69 for the total sum. A total of 39 individuals were re-tested, and the weighted kappa was 0.7. TFI correlated moderately with other frailty measures. The individual items correlated with alternative measures mostly as expected. In the confirmatory factor analysis (CFA), a three-factor model fitted the data better than a one-factor model. We found evidence for adequate reliability and validity of the Swedish TFI and potential for improvements.

Integrated care for older multimorbid heart failure patients: protocol for the ESCAPE randomized trial and cohort study

ESCAPE

Evaluation of a patient-centred biopsychosocial blended collaborative care pathway for the treatment of multimorbid elderly patients.

THERAPEUTIC AREA

Healthcare interventions for the management of older patients with multiple morbidities.

AIMS

Multi-morbidity treatment is an increasing challenge for healthcare systems in ageing societies. This comprehensive cohort study with embedded randomized controlled trial tests an integrated biopsychosocial care model for multimorbid elderly patients.

HYPOTHESIS

A holistic, patient-centred pro-active 9-month intervention based on the blended collaborative care (BCC) approach and enhanced by information and communication technologies can improve health-related quality of life (HRQoL) and disease outcomes as compared with usual care at 9 months.

METHODS

Across six European countries, ESCAPE is recruiting patients with heart failure, mental distress/disorder plus ≥2 medical co-morbidities into an observational cohort study. Within the cohort study, 300 patients will be included in a randomized controlled assessor-blinded two-arm parallel group interventional clinical trial (RCT). In the intervention, trained care managers (CMs) regularly support patients and informal carers in managing their multiple health problems. Supervised by a clinical specialist team, CMs remotely support patients in implementing the treatment plan-customized to the patients' individual needs and preferences-into their daily lives and liaise with patients' healthcare providers. An eHealth platform with an integrated patient registry guides the intervention and helps to empower patients and informal carers. HRQoL measured with the EQ-5D-5L as primary endpoint, and secondary outcomes, that is, medical and patient-reported outcomes, healthcare costs, cost-effectiveness, and informal carer burden, will be assessed at 9 and ≥18 months.

CONCLUSIONS

If proven effective, the ESCAPE BCC intervention can be implemented in routine care for older patients with multiple morbidities across the participating countries and beyond.

Associations of physical frailty with health outcomes and brain structure in 483 033 middle-aged and older adults: a population-based study from the UK Biobank

BACKGROUND

Physical frailty is a state of increased vulnerability to stressors and is associated with serious health issues. However, how frailty affects and is affected by numerous other factors, including mental health and brain structure, remains underexplored. We aimed to investigate the mutual effects of frailty and health using large, multidimensional data.

METHODS

For this population-based study, we used data from the UK Biobank to examine the pattern and direction of association between physical frailty and 325 health-related measures across multiple domains, using linear mixed-effect models and adjusting for numerous confounders. Participants were included if complete data were available for all five indicators of frailty, all covariates, and at least one health measure. We further examined the association between frailty and brain structure and the role of this association in mediating the relationship between frailty and health outcomes.

FINDINGS

483 033 participants aged 38-73 years were included in the study at baseline (between Dec 19, 2006, and Oct 1, 2010); at a median follow-up of 9 years (IQR 8-10), behavioural data were available for 46 501 participants and neuroimaging data for 40 210 participants. The severity of physical frailty was significantly associated with decreased cognitive performance (Cohen's d=0·025-0·162), increased early-life risks (d=0·026-0·111), unhealthy lifestyle (d=0·013-0·394), poor physical fitness (d=0·007-0·668), increased symptoms of poor mental health (d=0·032-0·607), severe environmental pollution (d=0·013-0·064), and adverse biochemical markers (d=0·025-0·198). Some associations were bidirectional, with the strongest effects on mental health measures. The severity of frailty correlated with increased total white matter hyperintensity and lower grey matter volume, particularly in subcortical regions (d=0·027-0·082), which significantly mediated the association between frailty and health-related outcomes, although the mediated effects were small.

INTERPRETATION

Physical frailty is associated with diverse unfavourable health-related outcomes, which can be mediated by differences in brain structure. Our findings offer a framework for guiding preventative strategies targeting both frailty and psychiatric disorders.

FUNDING

National Institute of Mental Health, National Science Foundation.

The bidirectional relationship between chronic joint pain and frailty: data from the Investigating Musculoskeletal Health and Wellbeing cohort

BACKGROUND

Pain and frailty are associated, but this relationship is insufficiently understood. We aimed to test whether there is a unidirectional or bidirectional relationship between joint pain and frailty.

METHODS

Data were from Investigating Musculoskeletal Health and Wellbeing, a UK-based cohort. Average joint pain severity over the previous month was assessed using an 11-point numerical rating scale (NRS). Frailty was classified as present/absent using the FRAIL questionnaire. Multivariable regression assessed the association between joint pain and frailty, adjusted for age, sex, and BMI class. Two-wave cross-lagged path modelling permitted simultaneous exploration of plausible causal pathways between pain intensity and frailty at baseline and 1-year. Transitions were assessed using t-tests.

RESULTS

One thousand one hundred seventy-nine participants were studied, 53% female, with a median age of 73 (range 60 to 95) years. FRAIL classified 176 (15%) participants as frail at baseline. Mean (SD) baseline pain score was 5.2 (2.5). Pain NRS ≥ 4 was observed in 172 (99%) of frail participants. Pain severity was associated with frailty at baseline (aOR 1.72 (95%CI 1.56 to 1.92)). In cross-lagged path analysis, higher baseline pain predicted 1-year frailty [β = 0.25, (95%CI 0.14 to 0.36), p < 0.001] and baseline frailty predicted higher 1-year pain [β = 0.06, (95%CI 0.003 to 0.11), p = 0.040]. Participants transitioning to frailty over one year had higher mean pain scores (6.4 (95%CI 5.8 to 7.1)) at baseline than those who remained non-frail (4.7 (95%CI 4.5 to 4.8)), p < 0.001.

CONCLUSIONS

The bidirectional relationship between pain and frailty could lead to a vicious cycle in which each accelerates the other's progression. This justifies attempts to prevent frailty by addressing pain and to include pain measures as an outcome in frailty studies.

Measuring Frailty Using Patient-Reported Outcomes (PRO) Data: A Feasibility Study in Patients with Multiple Myeloma

PURPOSE

The objective of this retrospective study was to determine the feasibility of measuring frailty using patient responses to relevant EORTC QLQ-C30 items as proxy criteria for the Fried Frailty Phenotype, in a cohort of patients with Relapsed/Refractory Multiple Myeloma (RRMM).

METHODS

Data were pooled from nine Phase III randomized clinical trials submitted to the FDA for regulatory review between 2010 and 2021, for the treatment of RRMM. Baseline EORTC QLQ-C30 responses were used to derive a patient-reported frailty phenotype (PRFP), based on the Fried definition of frailty. PRFP was assessed for internal consistency reliability, structural validity, and known groups validity.

RESULTS

This study demonstrated the feasibility of adapting patient responses to relevant EORTC QLQ-C30 items to serve as proxy Fried frailty criteria. Selected items were well correlated with one another and PRFP as a whole demonstrated adequate internal consistency reliability and structural validity. Known groups analysis demonstrated that PRFP could be used to detect distinct comorbidity levels and distinguish between different functional profiles, with frail patients reporting more difficulty in walking about, washing/dressing, and doing usual activities, as compared to their pre-frail and fit counterparts. Among the 4928 patients included in this study, PRFP classified 2729 (55.4%) patients as fit, 1209 (24.5%) as pre-frail, and 990 (20.1%) as frail.

CONCLUSION

Constructing a frailty scale from existing PRO items commonly collected in cancer trials may be a patient-centric and practical approach to measuring frailty. Additional psychometric evaluation and research is warranted to further explore the utility of such an approach.

Frailty Is a Risk Factor for Falls in the Older Adults: A Systematic Review and Meta-Analysis

OBJECTIVES

There is little evidence in the literature about the relationship between frailty and falls in older adults. Our objective was to explore the relationship between frailty and falls, and to analyze the effect factors (e.g., gender, different frailty assessment tools, areas, level of national economic development, and year of publication) of the association between frailty and falls among older adults.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Cohort studies that evaluated the association between frailty and falls in the older adults were included. We excluded any literature outside of cohort studies.

METHODS

We did a systematic literature search of English databases PubMed, Scopus, Web of Science, EBSCOhost, and SciElO, as well as the Chinese databases CNKI, WANFANG, and VIP from 2001 until October 2022. The eligible studies were evaluated for potential bias using the Newcastle-Ottawa Scale (NOS). Study selection, data extraction and assessment of study quality were each conducted by two investigators. In Stata/MP 17.0 software, we calculated pooled estimates of the prevalence of falls by using a random-effects model, Subgroup analysis was conducted based on gender, different frailty assessment tools, areas, level of economic development, and year of publication. The results are presented using a forest plot.

RESULTS

Twenty-nine studies were included in this meta-analysis and a total of 1,093,270 participants aged 65 years and above were enrolled. Among the older adults, frailty was significantly associated with a higher risk for falls, compared with those without frailty (combined RR-relative risk = 1.48, 95% CI-confidence interval: 1.27-1.73, I2=98.9%). In addition, the results of subgroup analysis indicated that men had a higher risk for falls than women among the older adults with frailty (RR 1.94, 95% CI: 1.18-3.2 versus RR 1.44, 95% CI: 1.24-1.67). Subgroup analysis by different frailty assessment tools revealed an increased risk of falls in older adults with frailty when assessed using the Frailty Phenotype (combined RR 1.32, 95%CI: 1.17-1.48), FRAIL score (combined RR 1.82, 95%CI: 1.36-2.43), and Study of Osteoporotic Fractures index (combined RR 1.54, 95%CI: 1.10-2.16). Furthermore, subgroup analysis by areas and level of national economic development found the highest fall risk in Oceania (combined RR 2.35, 95%CI: 2.28-2.43) and the lowest in Europe (combined RR 1.20, 95%CI: 1.05-1.38). Developed countries exhibited a lower fall risk compared to developing countries (combined RR 1.44, 95%CI: 1.21-1.71). Analysis by year of publication showed the highest fall risk between 2013-2019 (combined RR 1.79, 95%CI: 1.45-2.20) and the lowest between 2001-2013 (combined RR 1.21, 95%CI: 1.13-1.29).

CONCLUSION

Frailty represents a significant risk factor for falls in older adults, with the degree of risk varying according to the different frailty assessment tools employed, and notably highest when using the FRAIL scale. Additionally, factors such as gender, areas, level of national economic development, and healthcare managers' understanding of frailty may all impact the correlation between frailty and falls. Thus, it's imperative to select suitable frailty diagnostic tools tailored to the specific characteristics of the population in question. This, in turn, facilitates the accurate identification of frailty in older adults and informs the development of appropriate preventive and therapeutic strategies to mitigate fall risk.

Nutrition in Conservative Kidney Management: From Evidence to Practice

Conservative kidney management (CKM) is a treatment option for kidney failure, particularly for the elderly and those with co-morbidities. Dietitians can play an important role in the provision of CKM by enhancing patients' quality of life through the management of nutrition impact symptoms (symptoms that result in decreased eating, including anorexia, nausea, dry mouth, and taste changes), as well as symptoms that result from malnutrition, including fatigue, weakness, activity intolerance, slow wound healing, and low mood. There are many gaps in the literature regarding optimal nutritional recommendations for patients on CKM. More research is needed on symptom management and interventions to delay or slow the progression of malnutrition and frailty. This article provides an overview of important nutritional considerations, a synthesis of the current literature, and recommendations for application of evidence into the practice of CKM.

Development and validation of a prediction model for self-reported mobility decline in community-dwelling older adults

OBJECTIVES

The aim of this study is to develop and validate two models to predict 2-year risk of self-reported mobility decline among community-dwelling older adults.

STUDY DESIGN AND SETTING

We used data from a prospective cohort study of people aged 65 years and over in England. Mobility status was assessed using the EQ-5D-5L mobility question. The models were based on the outcome: Model 1, any mobility decline at 2 years; Model 2, new onset of persistent mobility problems over 2 years. Least absolute shrinkage and selection operator logistic regression was used to select predictors. Model performance was assessed using C-statistics, calibration plot, Brier scores, and decision curve analyses. Models were internally validated using bootstrapping.

RESULTS

Over 18% of participants who could walk reported mobility decline at year 2 (Model 1), and 7.1% with no mobility problems at baseline, reported new onset of mobility problems after 2 years (Model 2). Thirteen and 6 out of 31 variables were selected as predictors in Models 1 and 2, respectively. Models 1 and 2 had a C-statistic of 0.740 and 0.765 (optimism < 0.013), and Brier score = 0.136 and 0.069, respectively.

CONCLUSION

Two prediction models for mobility decline were developed and internally validated. They are based on self-reported variables and could serve as simple assessments in primary care after external validation.

Systematic review of the utility of the frailty index and frailty phenotype to predict all-cause mortality in older people

BACKGROUND

Current guidelines for healthcare of community-dwelling older people advocate screening for frailty to predict adverse health outcomes, but there is no consensus on the optimum instrument to use in such settings. The objective of this systematic review of population studies was to compare the ability of the frailty index (FI) and frailty phenotype (FP) instruments to predict all-cause mortality in older people.

METHODS

Studies published before 27 July 2022 were identified using Ovid MEDLINE, Embase, Scopus, Web of Science and CINAHL databases. The eligibility criteria were population-based prospective studies of community-dwelling older adults (aged 65 years or older) and evaluation of both the FI and FP for prediction of all-cause mortality. The Scottish Intercollegiate Guidelines Network's Methodology checklist was used to assess study quality. The areas under the receiver operator characteristic curves (AUC) were compared, and the proportions of included studies that achieved acceptable discriminatory power (AUC>0.7) were calculated for each frailty instrument. The results were stratified by the use of continuous or categorical formats of each instrument. The review was reported in accordance with the PRISMA and SWiM guidelines.

RESULTS

Among 8 studies (range: 909 to 7713 participants), both FI and FP had comparable predictive power for all-cause mortality. The AUC values ranged from 0.66 to 0.84 for FI continuous, 0.60 to 0.80 for FI categorical, 0.63 to 0.80 for FP continuous and 0.57 to 0.79 for FP categorical. The proportion of studies achieving acceptable discriminatory power were 75%, 50%, 63%, and 50%, respectively. The predictive ability of each frailty instrument was unaltered by the number of included items.

CONCLUSIONS

Despite differences in their content, both the FI and FP instruments had modest but comparable ability to predict all-cause mortality. The use of continuous rather than categorical formats in either instrument enhanced their ability to predict all-cause mortality.

Frailty and risks of all-cause and cause-specific death in community-dwelling adults: a systematic review and meta-analysis

Background

The associations of frailty with all-cause and cause-specific mortality remain unclear. Therefore, we performed this meta-analysis to fill this gap.

Methods

We searched the PubMed and Embase databases through June 2022. Prospective cohort studies or clinical trials examining frailty were evaluated, and the multiple adjusted risk estimates of all-cause and cause-specific mortality, such as death from cardiovascular disease (CVD), cancer, respiratory illness, dementia, infection, and coronavirus disease 2019 (COVID-19), were included. A random effects model was used to calculate the summary hazard ratio (HR).

Results

Fifty-eight studies were included for the qualitative systematic review, of which fifty-six studies were eligible for the quantitative meta-analysis, and the studies included a total of 1,852,951 individuals and more than 145,276 deaths. Compared with healthy adults, frail adults had a significantly higher risk of mortality from all causes (HR 2.40; 95% CI 2.17–2.65), CVD (HR 2.64; 95% CI 2.20–3.17), respiratory illness (HR 4.91; 95% CI 2.97–8.12), and cancer (HR 1.97; 95% CI 1.50–2.57). Similar results were found for the association between prefrail adults and mortality risk. In addition, based on the studies that have reported the HRs of the mortality risk per 0.1 and per 0.01 increase in the frailty index, we obtained consistent results.

Conclusions

The present study demonstrated that frailty was not only significantly related to an increased risk of all-cause mortality but was also a strong predictor of cause-specific mortality from CVD, cancer, and respiratory illness in community-dwelling adults. More studies are warranted to clarify the relationship between frailty and cause-specific mortality from dementia, infection, and COVID-19.

Trial registration

PROSPERO (CRD42021276021).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03404-w.

Agreement between standard and self-reported assessments of physical frailty syndrome and its components in a registry of community-dwelling older adults

BACKGROUND

The ability to identify frail older adults using a self-reported version of the physical frailty phenotype (PFP) that has been validated with the standard PFP could facilitate physical frailty detection in clinical settings.

METHODS

We collected data from volunteers (N = 182), ages 65 years and older, in an aging research registry in Baltimore, Maryland. Measurements included: standard PFP (walking speed, grip strength, weight loss, activity, exhaustion); and self-reported questions about walking and handgrip strength. We compared objectively-measured gait speed and grip strength to self-reported questions using Cohen's Kappa and diagnostic accuracy tests. We used these measures to compare the standard PFP with self-reported versions of the PFP, focusing on a dichotomized identification of frail versus pre- or non-frail participants.

RESULTS

Self-reported slowness had fair-to-moderate agreement (Kappa(k) = 0.34-0.56) with measured slowness; self-reported and objective weakness had slight-to-borderline-fair agreement (k = 0.10-0.21). Combining three self-reported slowness questions had highest sensitivity (81%) and negative predictive value (NPV; 91%). For weakness, three questions combined had highest sensitivity (72%), while all combinations had comparable NPV. Follow-up questions on level of difficulty led to minimal changes in agreement and decreased sensitivity. Substituting subjective for objective measures in our PFP model dichotomized by frail versus non/pre-frail, we found substantial (k = 0.76-0.78) agreement between standard and self-reported PFPs. We found highest sensitivity (86.4%) and NPV (98.7%) when comparing the dichotomized standard PFP to a self-reported version combining all slowness and weakness questions. Substitutions in a three-level model (frail, vs pre-frail, vs. non-frail) resulted in fair-to-moderate agreement (k = 0.33-0.50) with the standard PFP.

CONCLUSIONS

Our results show potential utility as well as challenges of using certain self-reported questions in a modified frailty phenotype. A self-reported PFP with high agreement to the standard phenotype could be a valuable frailty screening assessment in clinical settings.

Prediction models for functional status in community dwelling older adults: a systematic review

Background

Disability poses a burden for older persons, and is associated with poor outcomes and high societal costs. Prediction models could potentially identify persons who are at risk for disability. An up to date review of such models is missing.

Objective

To identify models developed for the prediction of functional status in community dwelling older persons.

Methods

A systematic review was performed including studies of older persons that developed and/or validated prediction models for the outcome functional status. Medline and EMBASE were searched, and reference lists and prospective citations were screened for additional references. Risk of bias was assessed using the PROBAST-tool. The performance of models was described and summarized, and the use of predictors was collated using the bag-of-words text mining procedure.

Results

Forty-three studies were included and reported 167 evaluations of prediction models. The median c-statistic values for the multivariable development models ranged between 0.65 and 0.76 (minimum = 0.58, maximum = 0.90), and were consistently higher than the values of the validation models for which median c-statistic values ranged between 0.6 and 0.68 (minimum = 0.50, maximum = 0.81). A total of 559 predictors were used in the models. The five predictors most frequently used were gait speed (n = 47), age (n = 38), cognition (n = 27), frailty (n = 24), and gender (n = 22).

Conclusions

No model can be recommended for implementation in practice. However, frailty models appear to be the most promising, because frailty components (e.g. gait speed) and frailty indexes demonstrated good to excellent predictive performance. However, the risk of study bias was high. Substantial improvements can be made in the methodology.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03156-7.

Modifiable predictive factors and all-cause mortality in the non-hospitalized elderly population: An umbrella review of meta-analyses

OBJECTIVE

This umbrella review aimed to summarize the association between modifiable predictive factors and all-cause mortality in the non-hospitalized elderly population, and estimated the credibility and strength of the current evidence.

METHODS

PubMed, Embase, Web of science, and EBSCOhost were searched up to February 28, 2022. Random-effect summary effect sizes and 95% confidence intervals (CIs), heterogeneity, small-study effect, excess significance bias, as well as 95% prediction intervals (PIs) were calculated. Methodological quality was assessed with the Assessment of Multiple Systematic Reviews 2 (AMSTAR-2) tool. The credibility of the included meta-analyses was graded from convincing to weak using established criteria. This umbrella review was registered with PROSPERO, CRD 42021282183.

RESULTS

In total, 32 predictive factors involving 49 associations extracted from 35 meta-analyses were analyzed. Forty-three of the 49 (87.8%) associations presented nominal significant effects by the random-effect model (P < 0.05), of which 34 had harmful associations and nine had beneficial associations with all-cause mortality. Frailty (FRAIL scale), low short physical performance battery (SPPB) score, and fewer daily steps carried a more than three-fold risk for all-cause mortality. Convincing evidence showed that weight fluctuation, prefrailty and frailty status, sarcopenia, low SPPB score, fewer daily steps, and fatigue increased the risk of all-cause mortality, while daily moderate-to-vigorous physical activity (MVPA) duration and total physical activity participation reduced the risk of death. There were twenty, nine, five, and six associations that yielded highly suggestive, suggestive, weak, and non-significant grades of evidence. Thirty-four (69.4%) of the associations exhibited significant heterogeneity. Twenty-two associations presented 95% PIs excluding the null value, two indicated small-study effects, and three had evidence for excess significance bias, respectively. The methodological quality of most meta-analyses was rated as low (37.1%) or critically low (42.9%).

CONCLUSIONS

A summary of the currently available meta-analyses suggests that a broad range of modifiable predictive factors are significantly associated with all-cause mortality risk in the non-hospitalized elderly population. The most credible evidence indicates that physical function represented by frailty and sarcopenia, as well as physical activity, are significant predictors for all-cause mortality. This umbrella review may provide prognostic information to direct appropriate diagnostic evaluation and treatment goals in the future. More solid evidence is still needed coming from moderate-to-high quality meta-analyses.

Relationship between Multimorbidity and Disability in Elderly Patients with Coexisting Frailty Syndrome

Background: Multimorbidity is a common problem worldwide. It carries the risk of reduced quality of life, disability, frequent hospitalizations, and death. The present study was designed to assess the relationships that exist between multimorbidity and disability in elderly patients. Methods: The study included 100 patients and was conducted between October 2020 and January 2021. Inclusion criteria included age >65 years, presence of a minimum of two comorbidities in the subject, and consent to participate in the study. Standardized survey instruments such as Tilburg Frailty Indicator (TFI), Charlson Comorbidities Index (CCI), Assessment of Basic Activities of Daily Living—Katz Scale (ADL), and Assessment of Complex Activities of Daily Living—Lawton Scale (IADL) were used in the study. Results: The majority of the subjects (92) had a frailty syndrome (TFI). A small group of respondents (8%) suffered from severe comorbidities (CCI). Among the subjects surveyed, 71% maintained full function in performing simple activities of daily living (ADL), while 29% demonstrated moderate disability on the scale. Full independence in performing complex activities of daily living (IADL) was present in 33% of the respondents, and 67% were partially independent. Independence in complex activities of daily living (IADL) was significantly higher in patients with fewer comorbidities. The severity of comorbidities (CCI) had a significant effect on the decrease in the level of independence (ADL and IADL). Independence in performing complex activities (IADL) was worse among older patients. Conclusions: An increase in the number of comorbidities contributes to a decrease in the level of performance of complex activities of daily living. The severity of comorbidities significantly reduces the level of independence of the subjects in simple and complex activities of daily living. In patients with a higher level of independence in performing simple and complex activities, the co-occurrence of frailty syndrome was less severe. As the age of the subjects increases, the frequency in which they show moderate dependence on third parties in performing complex activities of daily living increases.

Factors associated with persistence of symptoms 1 year after COVID-19: A longitudinal, prospective phone-based interview follow-up cohort study

OBJECTIVE

To investigate the persistence of symptoms compatible with COVID-19 in a real-file prospective cohort of patients at 12 months from hospital discharge.

METHODS

Longitudinal, prospective, single-center, cohort telephone follow-up (FU) study in a Tertiary Care Hospital. All consecutive patients >18 years admitted for COVID-19 were prospectively enrolled in a telephone FU program aimed at monitoring symptoms after 1,3,6,9 and 12 months from hospital discharge. The survey screened for somatic (fatigue, dyspnea, dyspnea, palpitations, cough, chest pain, abdominal pain, ageusia, anosmia, bowel symptoms) and emotional symptoms (insomnia, confusion, altered sense of reality, loss of appetite, fear, and depression) and frailty. Only patients with 12 months FU data were analyzed (N=254). Prevalence and factors associated with symptoms were the main outcomes. Frailty was defined by the presence of ≥3 indicators: weakness, slowness/impaired mobility, weight-loss, low physical activity, and exhaustion.

RESULTS

At 12 months, 40.5% of patients reported at least one symptom. The most common somatic ones were fatigue, exertional dyspnea, cough, bowel complaints while the most common psycho-emotional were insomnia, confusion, fear, and depression. Age, gender, gender, frailty, multiple symptoms at baseline and chronic obstructive pulmonary disease (COPD) were associated with symptoms persistence. Furthermore, frailty, COPD and multiple symptoms at baseline were associated with increased risk of somatic symptoms at 12 months, while age and gender were associated with emotional ones.

CONCLUSIONS

Burden of the long COVID-19 symptoms decreased over time but remained as high as 40% at 12 months with important gender and functional differences, highlighting potential patient categories who may benefit from specific follow up strategies.

Short-Term Changes of Frailty in Prematurely Aging Adults With Intellectual Disability

The purpose of this study was to investigate short-term changes of frailty in adults and identify predictors of frailty and disability changes between baseline and the follow-up. A cohort study was conducted in 85 adults with intellectual disability (ID) in southern Taiwan. Variables of frailty phenotype, Barthel Index, fall, comorbidity, and hospitalization were measured at baseline and at a 9-month follow-up. Descriptive statistics, correlations, and generalized linear model technique were used for data analysis. The percentages of frailty and pre-frail conditions were high at baseline. Improvement or deterioration on frailty was noticed in 37.6% of participants. Disability and comorbidity were significant predictors to changes in frailty, and severity of ID and frailty conditions were significant predictors to changes in disability.

Medical nutrition therapy using plant-focused low-protein meal plans for management of chronic kidney disease in diabetes

PURPOSE OF REVIEW

Nearly half of all Americans with chronic kidney disease (CKD) also have type-2-diabetes (T2D). Whereas traditional and emerging pharmacotherapies are increasingly frequently used for the management of CKD in diabetes (CKD/DM), the role of integrated or multimodal interventions including the potentially synergistic and additive effect of diet and lifestyle modifications in addition to pharmacotherapy has not been well examined, in sharp contrast to the well-known integrated approaches to heart disease.

RECENT FINDINGS

Low-carbohydrate low-fat diets are often recommended in T2D, whereas low-protein diets (LPD) are recommended by guidelines for nondiabetic CKD with increasing emphasis on plant-based protein sources. High-protein diets with greater animal protein lead to glomerular hyperfiltration, especially in patients with T2D, and faster decline in renal function. Guidelines provide differing recommendations regarding the amount (low vs high) and source (plant vs animal) of dietary protein intake (DPI) in CKD/DM. Some such as KDIGO recommend 0.8 g/kg/day based on insufficient evidence for DPI restriction in CKD/DM, whereas KDOQI and ISRNM recommend a DPI of 0.6 to <0.8 g/kg/day. A patient-centered plant-focused LPD for the nutritional management of CKD/DM (PLAFOND), a type of PLADO diet comprising DPI of 0.6 to <0.8 g/kg/day with >50% plant-based sources, high dietary fiber, low glycemic index, and 25-35 Cal/kg/day energy, can be implemented by renal dietitians under Medical Nutrition Therapy.

SUMMARY

Potential risks vs benefits of high vs low protein intake in CKD/DM is unknown, for which expert recommendations remain opinion based. Randomized controlled studies are needed to examine safety, acceptability and efficacy of PLAFOND.

Associations between inflammation, cardiovascular biomarkers and incident frailty: the British Regional Heart Study

Introduction

cardiovascular disease (CVD) and chronic inflammation are implicated in the development of frailty. Longitudinal analyses of inflammatory markers, biomarkers of cardiac dysfunction and incidence of frailty are limited.

Methods

in the British Regional Heart Study, 1,225 robust or pre-frail men aged 71–92 years underwent a baseline examination, with questionnaire-based frailty assessment after 3 years. Frailty definitions were based on the Fried phenotype. Associations between incident frailty and biomarkers of cardiac dysfunction (high-sensitivity cardiac troponin T (hs-cTnT), N-terminal pro B-type natriuretic peptide (NT-proBNP)) and inflammation (C-reactive protein (CRP) and interleukin-6 (IL-6)) were examined, by tertile, with the lowest as reference.

Results

follow-up data were available for 981 men. Ninety one became frail. Adjusted for age, pre-frailty, prevalent and incident CVD, comorbidity, polypharmacy and socioeconomic status, IL-6 (third tertile OR 2.36, 95% CI 1.07–5.17) and hs-cTnT (third tertile OR 2.24, 95% CI 1.03–4.90) were associated with increased odds of frailty. CRP (third tertile OR 1.83, 95% CI 0.97–4.08) and NT-proBNP (second tertile OR 0.48, 95% CI 0.23–1.01) showed no significant association with incident frailty. The top tertiles of CRP, IL-6, hscTnT and NT-proBNP were strongly associated with mortality prior to follow-up.

Conclusion

IL-6 is associated with incident frailty, supporting the prevailing argument that inflammation is involved in the pathogenesis of frailty. Cardiomyocyte injury may be associated with frailty risk. Associations between elevated CRP and frailty cannot be fully discounted; NT-proBNP may have a non-linear relationship with incident frailty. CRP, IL-6, hs-cTnT and NT-proBNP are vulnerable to survivorship bias.

Subclinical cardiovascular disease and risk of incident frailty: The British Regional Heart Study

BACKGROUND/OBJECTIVES

Subclinical cardiovascular disease (CVD) is cross-sectionally associated with frailty, but the relationship between subclinical CVD and incident frailty has not been reported. We aimed to assess this prospective association.

DESIGN

Longitudinal analysis of data from the British Regional Heart Study, a prospective cohort study.

PARTICIPANTS

1057 men, aged 71-92 years, robust or pre-frail at baseline, and without a clinical diagnosis of CVD.

MEASUREMENTS

Participants underwent baseline measurement of carotid-femoral pulse wave velocity (cfPWV), carotid intima-media thickness (CIMT), carotid distensibility coefficient (DC), and ankle-brachial pressure index (ABPI), and had questionnaire-based frailty assessment after three years. Frailty status was based on the Fried phenotype. Multivariate logistic regressions examined associations between incident frailty and tertile of cfPWV, CIMT, DC, and ABPI group (<0.9, 0.9-1.4, ≥1.4).

RESULTS

865 men were examined and completed the 3 year follow-up questionnaire, of whom 78 became frail. Adjusted for age, prefrailty, body mass index, diabetes, smoking, atrial fibrillation, blood pressure, renal function, and incident CVD, higher CIMT was associated with greater odds of incident frailty (2nd tertile OR 1.62, 95% CI 0.78-3.35, 3rd tertile OR 2.61, 95% CI 1.30-5.23, p = 0.007, trend p = 0.006). cfPWV showed a weaker, non-significant association (2nd tertile OR 1.79, 95% CI 0.85-3.78, 3rd tertile OR 1.73, OR 0.81-3.72, p = 0.16, trend p = 0.20). There was no clear association between incident frailty and DC or ABPI. In subgroup analyses, CIMT was significantly associated with incident frailty in men ≥80 years (3rd tertile OR 6.99, 95%CI 1.42-34.5), but not in men aged 75-80 or < 75 years.

CONCLUSION

Subclinical CVD, as measured by CIMT, is associated with greater risk of incident frailty in older men over three year follow-up, independent of the development of clinically-apparent stroke, heart failure, or myocardial infarction, and may be a modifiable risk factor for frailty. This association may be stronger in very old age.

Frailty, aging, and periodontal disease: Basic biologic considerations

Aging is associated with the development of disease. Periodontal disease is one of the many diseases and conditions that increase in prevalence with age. In addition to the traditional focus on individual age-related conditions, there is now a greater recognition that multisystem conditions such as frailty play an important role in the health of older populations. Frailty is a clinical condition in older adults that increases the risk of adverse health outcomes. Both frailty and periodontal disease are common chronic conditions in older populations and share several risk factors. There is likely a bidirectional relationship between periodontal disease and frailty. Comorbid systemic diseases, poor physical functioning, and limited ability to self-care in frail older people have been implicated as underlying the association between frailty and periodontal disease. In addition, both frailty and periodontal disease also have strong associations with inflammatory dysregulation and other age-related pathophysiologic changes that may similarly underlie their development and progression. Investigating age-related changes in immune cells that regulate inflammation may lead to a better understanding of age-related disease and could lead to therapeutic targets for the improved management of frailty and periodontal disease.

Risk Factors for Mobility Decline in Community-Dwelling Older Adults: A Systematic Literature Review

Mobility is essential to maintaining independence for older adults. This systematic review aimed to summarize evidence about self-reported risk factors for self-reported mobility decline; and to provide an overview of published prognostic models for self-reported mobility decline among community-dwelling older adults. Databases were searched from inception to June 2, 2020. Studies were screened by two independent reviewers who extracted data and assessed study quality. Sixty-one studies (45,187 participants) were included, providing information on 107 risk factors. High-quality evidence and moderate/large effect sizes for the association with mobility decline were found for older age beyond 75 years, the presence of widespread pain, and mobility modifications. Moderate-high quality evidence and small effect sizes were found for a further 21 factors. Three model development studies demonstrated acceptable model performance, limited by high risk of bias. These findings should be considered in intervention development, and in developing a prediction instrument for practical application.

Asthma is associated with frailty among community-dwelling adults: the GAZEL cohort

Introduction

Early management of chronic respiratory diseases (CRDs) and frailty have been identified as key targets towards healthy ageing, but the association between CRDs and frailty has been poorly investigated. We studied the association between asthma and frailty in adults of the GAZEL cohort using different definitions of asthma over the 26 years of follow-up.

Methods

Current asthma definitions are based on yearly self-reports of symptoms or medication (in 2015, constant reports or at least one report between 1990 and 2015), or on a detailed respiratory symptoms questionnaire in 2002. Frailty definition is based on weakness, fatigue, unintentional weight loss, low physical activity and mobility in 2015. Frail participants had three criteria or more, pre-frail 1 or 2, and robust 0. Multinomial regression models adjusted for age, sex, body mass index, smoking, education, marital status and comorbidities were performed.

Results

In 2015, 12 345 adults (73% men, 61 to 77 years old) were included: 3% of them reported current asthma, 1.6% had constant reports during the follow-up and 9% reported current asthma at least once. In 2015, 6% were frail, 34% pre-frail and 13% of current asthmatics and 6% of non-asthmatics were frail (adjusted OR (aOR) 2.19 (1.44 to 3.34)). Significant associations were also found with the 2002 definition (aOR 2.24 (1.73 to 2.90)), constant reports (aOR 3.67 (1.70 to 7.93)) or at least once (aOR 1.50 (1.15 to 1.98)). Current asthma was also associated with pre-frailty with the 2002 definition (aOR 1.46 (1.26 to 1.68)).

Discussion

Participants with asthma had increased risk of frailty. A better understanding of their relationship could help to define and evaluate strategies for a better ageing of asthmatics.

Association between self-reported or perceived fatigue and falls among older people: A systematic review

AIM

The aim of the present review was to examine the evidence of the relationship between self-reported or perceived fatigue and falls among older adults.

METHODS

A systematic review, following the PRISMA recommendations, was performed. PubMed, Scopus, Web of Science, and Cinahl were searched from February 2021 until March 2021, without any limitation on publication date. The methodological quality of the recruited studies was assessed with the Newcastle-Ottawa scale.

RESULTS

Of the 2,296 initially retrieved records, 20 met the inclusion criteria; 11 cohort and 9 cross-sectional studies. They were classified as "good or very good" studies. Data on 59,852 older adults was reported. Most studies reported a strong association between fatigue and incidence or risk of falls, with odds ratios ranging from 1.04 to 3.53. Evidence obout the relationship between fatigue and recurrent, as well as injurious, falls is limited.

CONCLUSIONS

Self-reported or perceived fatigue is associated with the incidence of falls or risk of falling among older adults. Nurses could contribute to decreasing the inicdence of falls through prevention and proper geriatric assessment, including the management of fatigue in their daily clinical practice. The evidence about the potential effect of fatigue on falls-related injuries is inconclusive and on recurrent falls remains to be further defined.

Identifying Patients with Osteoarthritis at Risk of Sarcopenia using the SARC-F

Background

Sarcopenia is an important modifiable risk factor in patients being considered for elective knee or hip replacement as it may be associated with a higher risk of post-operative joint replacement complications. Our objectives are to determine the prevalence of patients with osteoarthritis at risk of sarcopenia by using the SARC-F tool, and whether risk of sarcopenia is associated with referral to an orthopaedic surgeon.

Methods

We conducted a retrospective review of patients who were 60 years or older assessed at four Canadian musculoskeletal assessment centres. Patients completed the SARC-F as part of their assessment. Multivariable logistic regression analyses were conducted to determine association between risk of sarcopenia and the odds of referral to an orthopedic surgeon for surgical consultation.

Results

3,697 patients were included and 67.8% (2,508/3,697) were at risk of sarcopenia. Prevalence was highest in those assessed for hip replacement at 72.3% (635/878). Patients at risk of sarcopenia were more likely to be referred to an orthopaedic surgeon (OR 1.299; SD 1.074–1.571).

Conclusions

Patients with osteoarthritis assessed for joint replacement are at high risk of sarcopenia, particularly individuals undergoing potential hip replacement. Patients at risk of sarcopenia are more likely to be referred to orthopaedic surgery for surgical consultation.

Physical frailty and health-related quality of life among Chinese rural older adults: a moderated mediation analysis of physical disability and physical activity

OBJECTIVES

The purpose of this study is to explore the mediating effect of physical disability as well as the role of physical activity (PA) as a moderator in the relationship between physical frailty and health-related quality of life (HRQoL) among rural older adults in China.

DESIGN

Cross-sectional analysis.

SETTING

Rural households in Shandong of China (Rushan, Qufu, Laolin).

PARTICIPANTS AND METHODS

A survey was conducted among 3243 rural older adults. The data were collected using questionnaires measuring physical frailty, physical disability, HRQoL and PA. Bootstrap analyses were employed to explore the mediating effect of physical disability and also the moderating role of PA on physical frailty and HRQoL.

RESULTS

After controlling for age and education, physical disability partially mediated the effect of physical frailty on HRQoL (indirect effect=-0.143, 95% CI -0.175 to -0.113), with the mediating effect accounting for 33.71% of the total effect. PA moderated the relationship between physical frailty and physical disability as well as the relationship between physical disability and HRQoL. Specifically, the interaction term between physical frailty and PA significantly predicted physical disability (β=-0.120, t=-7.058, p<0.001), and the interaction term between physical disability and PA also had a significant predictive effect on HRQoL (β=0.115, t=6.104, p<0.001).

CONCLUSIONS

PA appears to moderate the indirect effect of physical disability on the association between physical frailty and HRQoL. This study provides support for potential mechanisms in the association between physical frailty and HRQoL. Encouraging rural older adults to increase PA appropriately might improve HRQoL for older adults with physical frailty and physical disability problems.

Self-reported fatigue: A significant risk factor for falling in older women and men

OBJECTIVE

To determine whether fatigue may be a risk factor for falling in older men and women, independent of other components of the frailty phenotype, fear of falling, and physical performance.

DESIGN

Among 986 women and 485 men visiting a health resort (mean age 72.3 and 72.7, respectively), subjects with at least one fall in the previous year were compared with non-fallers using a multivariate logistic regression analysis. Age, fatigue and fear of falling over the previous month were assessed by visual analogue scale (VAS), and the past 7 days of activity were assessed using the International Physical Activity Questionnaire. The following parameters were also assessed: weight loss in the past year, maximum grip strength measured with a hand dynamometer, time to perform the 5-chair stand and the up and go tests, time to walk 4 m, time held on one leg, feet together, as well as in the semi-tandem and tandem positions.

RESULTS

A feeling of fatigue (VAS score ≥ 5/10 in women or ≥4/10 in men), a fear of falling (VAS score ≥ 4/10 in women or ≥2 in men), and poor balance (time held in semi-tandem position < 10 s in women and time held on one leg < 6.5 s in men) were the 3 independent parameters distinguishing fallers from non-fallers.

CONCLUSION

The present study suggests the interest of adding a VAS score of fatigue to that of fear of falling and balance measurements for screening men and women aged 65 or older who are at risk of falls.

Prediction of Mortality by the Tilburg Frailty Indicator (TFI)

OBJECTIVE

To predict mortality with the Tilburg Frailty Indicator (TFI) in a sample of community-dwelling older people, using a follow-up of 7 years.

DESIGN

Longitudinal.

SETTING AND PARTICIPANTS

479 Dutch community-dwelling people aged 75 years or older.

MEASUREMENTS

The TFI, a self-report questionnaire, was used to collect data about total, physical, psychological, and social frailty. The municipality of Roosendaal (a town in the Netherlands) provided the mortality dates.

RESULTS

Total, physical, and psychological frailty predicted mortality, with unadjusted hazard ratios of 1.295, 1.168, and 1.194, and areas under the receiver operating characteristic curves of 0.664, 0.671, and 0.567, respectively. After adjustment for age and gender, the areas under the curves for total, physical, and psychological frailty were 0.704, 0.702, and 0.652, respectively. Analyses using individual components of the TFI show that difficulty in walking and unexplained weight loss predict mortality.

CONCLUSIONS AND IMPLICATIONS

This study has shown the predictive validity of the TFI for mortality in community-dwelling older people. Our study demonstrated that physical and psychological frailty predicted mortality. Of the individual TFI components, difficulty in walking consistently predicted mortality. For identifying frailty, using the integral instrument is recommended because total, physical, psychological, and social frailty and its components have proven their value in predicting adverse outcomes of frailty, for example, increase in health care use and a lower quality of life.

Examining Frailty Phenotype Dimensions in the Oldest Old

INTRODUCTION

Frailty has been studied among the old population due to its association with negative outcomes. Presently there is no gold standard for measuring frailty, but several studies have used the frailty phenotype of Fried consisting of five components (weakness, slowness, unintentional weight loss, exhaustion, and low physical activity) that classify individuals as robust, pre-frail, or frail, depending on the number of components affected, respectively, zero, one or two, and three or more. This study aims to explore the specific contribution of each of these components to the frailty phenotype in a sample of oldest old community-dwelling individuals.

MATERIALS AND METHODS

Individuals aged 80+ years old living in the community (N = 142) participated in this study. Sociodemographic data (age, sex, educational level, and marital status) and Fried's frailty phenotype were collected. Descriptive analysis summarized sociodemographic information and the frailty components. Multiple correspondence analysis (MCA) was performed to detect and explore relationships between frailty's five components.

RESULTS

Participants had a mean age of 88.07 years (SD = 5.30 years) and were mainly women (73.9%). The majority of the sample were considered frail (71.8%) and pre-frail (24.7%), and the most recurrent component for both groups was slowness. From the MCA analysis, a two-dimension solution was considered the most adequate, with 53.47% of variance explained. Dimension 1 (32.21% of variance explained) showed weakness as the most discriminant component; dimension 2 (21.26% of variance explained) showed unintentional weight loss as the most discriminant component.

DISCUSSION

Results revealed a high number of pre-frail and frail participants. MCA proved to add an important understanding in examining the frailty phenotype; it revealed weakness as the most discriminant component for dimension 1, suggesting a high association with the frailty phenotype. MCA also identified two main features of frailty: one related with physical features (motor behavioral and grip strength) including weakness, low physical activity, and slowness; and the second related with intrinsic conditions (unintentional weight loss and exhaustion).

CONCLUSION

This study corroborates the need of a differentiated approach to the frailty phenotype among very old individuals, bringing for consideration the specific influence of its components.

Reliability and validity of the self-reported frailty screening questionnaire in older adults

BACKGROUND

Frailty is one of the most important risk factors for adverse outcomes in older adults. Despite a high prevalence, there is still a lack of frailty screening instruments specific to Chinese older adults. We developed a simple frailty screening questionnaire (FSQ) that could predict long-term mortality. We aimed to explore the reliability and construct validity of this new measurement tool.

METHODS

A total of 205 individuals aged 65 years or older were recruited in this study. The FSQ and frailty phenotype were assessed. The FSQ included self-reported slowness, weakness, weight loss, inactivity, and exhaustion. A subgroup of 109 participants completed the FSQ a second time 2 weeks later for test-retest reliability. Frailty phenotype included slowness, exhaustion, weight loss, weakness, and inactivity.

RESULTS

The intraclass correlation coefficient for the FSQ, slowness, weakness, weight loss, inactivity and exhaustion were 0.937, 0.938, 0.934, 0.921, 0.826, and 0.832, respectively. Using a cut-off of 3, the sensitivity, specificity, and area under the curve of the receiver operating characteristic were 52.6%, 93.5%, and 0.883 (p < 0.001), respectively. The kappa coefficient between the FSQ and frailty phenotype was 0.431 (p < 0.001). FSQ score was negatively correlated with walking speed and grip strength, and positively correlated with age. Frailty defined by the FSQ was associated with older age, chronic diseases, and worse physical function.

CONCLUSIONS

The FSQ is a potentially useful, reliable, and valid instrument in screening frailty in older adults, and can be recommended to identify frailty in clinical settings.

Association Between Life-Course Obesity and Frailty in Older Adults: Findings in the GAZEL Cohort

OBJECTIVE

This study aimed to assess the relationship between weight history during adulthood and frailty in late life in men and women participating in the GAZEL (GAZ and ELectricité) cohort.

METHODS

This cohort study included 8,751 men and 3,033 women (aged 61 to 76 years) followed up since 1989. Modified Fried's frailty criteria (weakness, fatigue, unintentional weight loss, low physical activity, and impaired mobility) were assessed in 2015. Reported BMI was determined each year to characterize: obesity status in 2015, obesity duration over the 1990 to 2015 period, and trajectories of BMI. Associations between frailty and weight history were assessed using multinomial regression.

RESULTS

In 2015, 12% of men had obesity, 1.8% severe obesity, and 0.4% morbid obesity; for women, these percentages were 11%, 2.2%, and 0.8%, respectively. Individuals with obesity were more likely to be frail than those with normal BMI and the risk of frailty increased with each additional year of obesity (adjusted odds ratio 1.04 [1.00-1.08] for men and 1.07 [1.02-1.13] for women). Trajectories of BMI revealed that both long-term obesity and onset of obesity in late adulthood were associated with frailty.

CONCLUSIONS

Current and past obesity appear to be important determinants of frailty. Early weight management may be beneficial in old age.

Frailty Defined by FRAIL Scale as a Predictor of Mortality: A Systematic Review and Meta-analysis

OBJECTIVES

To conduct a systematic review of the literature on prospective cohort studies examining mortality risk according to frailty defined by FRAIL scale, and to perform a meta-analysis to synthesize the pooled risk estimates.

DESIGN

Systematic review and meta-analysis.

SETTING

Embase, Scopus, MEDLINE, CINAHL, and PsycINFO were systematically searched in March 2018. References of included studies were reviewed and a forward citation tracking was performed on relevant review papers for additional studies. Additional data necessary for a meta-analysis were requested from corresponding authors.

PARTICIPANTS

Community-dwelling middle-aged and older adults.

MEASUREMENTS

Mortality risk due to frailty as defined by the FRAIL scale.

RESULTS

After removing duplicates, there are 81 citations for title, abstract, and full-text screening. Eight studies were included in this review. Four studies calculated the area under the receiver operating characteristic curve, which ranged from 0.54 to 0.70. A random-effects meta-analysis was conducted on 3 studies that provided adjusted hazard ratios (HRs) of mortality risk according to 3 frailty groups (robust, prefrail, and frail) defined by FRAIL scale. Both frailty and prefrailty were significantly associated with higher mortality risk than robustness [pooled HR = 3.53, 95% confidence interval (CI) = 1.66-7.49, P = .001; pooled HR = 1.75, 95% CI = 1.14-2.70, P = .01, respectively]. No evidence of publication bias was observed.

CONCLUSION

This study demonstrated that FRAIL scale is a tool that can effectively identify frailty/prefrailty status, as well as quantify frailty status in a graded manner in relation to mortality risk. Although its feasibility is of note, not many studies are yet using this relatively new tool. More studies are warranted regarding mortality and other health outcomes.

Association between frailty and incident risk of disability in community-dwelling elder people: evidence from a meta-analysis

OBJECTIVE

Frailty is considered to be one of the risk factors of disability. However, the results of original reported studies are not consistent with respect to the frailty and incidence of disability, and previously published meta-analyses have also shown inconsistent results. This meta-analysis was conducted to investigate the relationship between the different stages of frailty and the incidence of disability by examining updated overall trends in community-dwelling elders.

STUDY DESIGN

Cohort studies in English or Chinese based on associations between frailty and incident disability risks that were published from 2000 until the current date were researched using PubMed, Embase, Web of Science, and CENTRAL databases.

METHODS

The Q test and I² statistic were used to examine between-study heterogeneity. Random-effect models were adopted to synthesize the results based on the study heterogeneity. Subgroup analyses were also conducted to explore the possible sources of between-study heterogeneity based on the characteristics of participants.

RESULTS

Eighteen cohort studies with 88,906 participants were included in our meta-analyses. Compared with the non-frailty category, the combined relative risks (RRs) (95% confidence interval [CI]) of the disability were 1.66 (1.49-1.85) and 2.53 (2.01-3.14) for the category of prefrailty and frailty, respectively. Results suggested that the incident risk of disability at follow-up times <5 (RR = 3.19, 95% CI = 2.25-4.53) was significantly higher than for follow-up times ≥5 in the frailty category (RR = 2.00, 95% CI = 1.55-2.56). The risk in a sample size of ≥1000 (RR = 2.78, 95% CI = 2.04-3.14) was significantly higher than that when the sample size was <1000 (RR = 1.91, 95% CI = 1.53-2.37) in the frailty group. Compared with a value adjusted for comorbidity, the unadjusted comorbidity was significantly higher in the prefrailty category (1.90 vs. 1.52). Compared with a value adjusted for education, the unadjusted education was significantly higher in the prefrailty category (1.81 vs. 1.46). No publication bias was observed.

CONCLUSION

The overall meta-analysis confirms that frailty has significantly increased the incident risk of disability. Frail, elderly people are at the highest risk of future disability and may be adequate candidates for taking part in prevention and intervention programs.

Oral Health, Disability and Physical Function: Results From Studies of Older People in the United Kingdom and United States of America

OBJECTIVES

Studies examining the associations between oral health and disability have limited oral health measures. We investigated the association of a range of objectively and subjectively assessed oral health markers with disability and physical function in older age.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analyses were based on the British Regional Heart Study (BRHS) comprising men aged 71 to 92 years (n = 2147) from 24 British towns, and the Health, Aging, and Body Composition (HABC) Study comprising men and women aged 71 to 80 years (n = 3075) from the United States. Assessments included oral health (periodontal disease, tooth count, dry mouth, and self-rated oral health), disability, and physical function (grip strength, gait speed, and chair stand test).

RESULTS

In the BRHS, dry mouth, tooth loss, and cumulative oral health problems (≥3 problems) were associated with mobility limitations and problems with activities of daily living and instrumental activities of daily living; these remained significant after adjustment for confounding variables (for ≥3 dry mouth symptoms, odds ratio (OR) 2.68, 95% confidence interval (CI) 1.94-3.69; OR 1.76, 95% CI 1.15-2.69; OR 2.90, 95% CI 2.01, 4.18, respectively). Similar results were observed in the HABC Study. Dry mouth was associated with the slowest gait speed in the BRHS, and the weakest grip strength in the HABC Study (OR 1.75, 95% CI 1.22, 2.50; OR 2.43, 95% CI 1.47-4.01, respectively).

CONCLUSIONS AND IMPLICATIONS

Markers of poor oral health, particularly dry mouth, poor self-rated oral health, and the presence of more than 1 oral health problem, were associated with disability and poor physical function in older populations. Prospective investigations of these associations and underlying pathways are needed.

Longitudinal Relationship Between Frailty and Cognition in Patients 50 Years and Older with Breast Cancer

OBJECTIVES

To evaluate relationships between frailty and cognition longitudinally in adults 50 years and older with breast cancer receiving chemotherapy.

DESIGN

Secondary analysis of a prospective longitudinal observational study.

SETTING

University of Rochester NCI Community Oncology Research Program community oncology clinics.

PARTICIPANTS

Patients with breast cancer age 50 and older receiving adjuvant/neoadjuvant chemotherapy (n = 376) and age-matched controls without cancer (n = 234).

MEASUREMENTS

Frailty was assessed using a modified frailty score from self-reported assessments (weakness, exhaustion, physical activity, and gait speed). Cognition was assessed by patient report (Functional Assessment of Cancer Therapy-Cognition [FACT-Cog]) and objective measures. Frailty and cognition were measured at three time points (prechemotherapy [A1], postchemotherapy [A2], and 6 months postchemotherapy [A3]; similar time interval for controls). Linear regression models evaluated associations between frailty and cognition adjusting for covariates.

RESULTS

The average age was 59 years (standard deviation = 6.4 y). At baseline, patients with cancer had a higher mean frailty score (1.21 vs .73; P < .001) and lower mean FACT-Cog score (158.4 vs 167.3; P < .001) compared with controls. Objective cognitive measures were not statistically different. Longitudinal decline in FACT-Cog between A1 and A2 (P < .05) and between A1 and A3 (P < .01) was associated with increased frailty score in patients compared with controls. Longitudinal worsening in Controlled Oral Word Association (P < .05) and Trail-Making Test (P < .01) were associated with an increase in frailty between A1 and A2 in patients compared with controls; longitudinal decline in the Delayed Match to Sample test was associated with an increase in frailty between A1 and A3 (P < .05) in patients compared with controls. This finding remained significant for a subset analysis of those aged 65 and older.

CONCLUSION

In patients with breast cancer aged 50 and older, longitudinal decline in FACT-Cog and objective measures of attention and memory were associated with increased frailty during treatment and up to 6 months posttreatment. Overall, our study suggests cognition and frailty are both important factors to assess in breast cancer patients. J Am Geriatr Soc 67:928-936, 2019.

Physical frailty in older men: prospective associations with diet quality and patterns

BACKGROUND

increasing numbers of older adults are living with frailty and its adverse consequences. We investigated relationships between diet quality or patterns and incident physical frailty in older British men and whether any associations were influenced by inflammation.

METHODS

prospective study of 945 men from the British Regional Heart Study aged 70-92 years with no prevalent frailty. Incident frailty was assessed by questionnaire after 3 years of follow-up. Frailty was defined as having at least three of: low grip strength, low physical activity, slow walking speed, unintentional weight loss and feeling of low energy, all based on self-report. The Healthy Diet Indicator (HDI) based on WHO dietary guidelines and the Elderly Dietary Index (EDI) based on a Mediterranean-style dietary intake were computed from questionnaire data and three dietary patterns were identified using principal components analysis: prudent, high fat/low fibre and high sugar.

RESULTS

men in the highest EDI category and those who followed a prudent diet were less likely to become frail [top vs bottom category odds ratio (OR) (95% CI) 0.49 (0.30, 0.82) and 0.53 (0.30, 0.92) respectively] after adjustment for potential confounders including BMI and prevalent cardiovascular disease. No significant association was seen for the HDI. By contrast those who had a high fat low fibre diet pattern were more likely to become frail [OR (95% CI) 2.54 (1.46, 4.40)]. These associations were not mediated by C-reactive protein (marker of inflammation).

CONCLUSIONS

the findings suggest adherence to a Mediterranean-style diet is associated with reduced risk of developing frailty in older people.

The prevalence of frailty among acute stroke patients, and evaluation of method of assessment

Objective:

We aimed to determine prevalence of pre-stroke frailty in acute stroke and describe validity of a Frailty Index–based assessment.

Design:

Cross-sectional.

Setting:

Single UK urban teaching hospital.

Subjects:

Consecutive acute stroke unit admissions, recruited in four waves (May 2016–August 2018). We performed the assessments within first week and attempted to include all admissions.

Main measures:

Our primary measure was a Frailty Index, based on cumulative disorders. A proportion of participants were also assessed with the ‘Frail non-disabled’ questionnaire. We evaluated concurrent validity of Frailty Index against variables associated with frailty in non-stroke populations. We described predictive validity of Frailty Index for stroke severity and delirium. We described convergent validity, quantifying agreement between frailty assessments and a measure of pre-stroke disability (modified Rankin Scale) using kappa statistics and correlations.

Results:

We included 546 patients. A Frailty Index–defined frailty syndrome was observed in 427 of 545 patients (78%), of whom, 151 (28%) had frank frailty and 276 (51%) were pre-frail. Phenotypic frailty was observed in 72 of 258 patients (28%). We demonstrated concurrent validity via significant associations with all variables (all p < 0.01). We demonstrated predictive validity for stroke severity and delirium ( p < 0.01). Agreement between the frailty measures was poor (kappa = –0.06) and convergent validity was moderate (Frail non-disabled ‘Cramer’s V’ = 0.25; modified Rankin Scale ‘Cramer’s V’ = 0.47).

Conclusion:

Frailty is present in around one in four patients with acute stroke; if pre-frailty is included, then a frailty syndrome is seen in three out of four patients. The Frailty Index is a valid measure of frailty in stroke; however, there is little agreement between this scale and other measurements of frailty.

The ability of four frailty screening instruments to predict mortality, hospitalization and dependency in (instrumental) activities of daily living

The aim of this study was to assess the predictive ability of the frailty phenotype (FP), Groningen Frailty Indicator (GFI), Tilburg Frailty Indicator (TFI) and frailty index (FI) for the outcomes mortality, hospitalization and increase in dependency in (instrumental) activities of daily living ((I)ADL) among older persons. This prospective cohort study with 2-year follow-up included 2420 Dutch community-dwelling older people (65+, mean age 76.3 ± 6.6 years, 39.5% male) who were pre-frail or frail according to the FP. Mortality data were obtained from Statistics Netherlands. All other data were self-reported. Area under the receiver operating characteristic curves (AUC) was calculated for each frailty instrument and outcome measure. The prevalence of frailty, sensitivity and specificity were calculated using cutoff values proposed by the developers and cutoff values one above and one below the proposed ones (0.05 for FI). All frailty instruments poorly predicted mortality, hospitalization and (I)ADL dependency (AUCs between 0.62–0.65, 0.59–0.63 and 0.60–0.64, respectively). Prevalence estimates of frailty in this population varied between 22.2% (FP) and 64.8% (TFI). The FP and FI showed higher levels of specificity, whereas sensitivity was higher for the GFI and TFI. Using a different cutoff point considerably changed the prevalence, sensitivity and specificity. In conclusion, the predictive ability of the FP, GFI, TFI and FI was poor for all outcomes in a population of pre-frail and frail community-dwelling older people. The FP and the FI showed higher values of specificity, whereas sensitivity was higher for the GFI and TFI.

Hereditary Hemochromatosis Associations with Frailty, Sarcopenia and Chronic Pain: Evidence from 200,975 Older UK Biobank Participants

BACKGROUND

Iron is essential for life but contributes to oxidative damage. In Northern-European ancestry populations, HFE gene C282Y mutations are relatively common (0.3%-0.6% rare homozygote prevalence) and associated with excessive iron absorption, fatigue, diabetes, arthritis, and liver disease, especially in men. Iron excess can be prevented or treated but diagnosis is often delayed or missed. Data on sarcopenia, pain, and frailty are scarce.

METHODS

Using 200,975 UK Biobank volunteers aged 60-70 years, we tested associations between C282Y homozygosity with Fried frailty, sarcopenia, and chronic pain using logistic regression adjusted for age and technical genetic covariates. As iron overload is progressive (with menstruation protective), we included specific analyses of older (65-70 years) females and males.

RESULTS

One thousand three hundred and twelve (0.65%) participants were C282Y homozygotes; 593 were men (0.62%) and 719 were women (0.68%). C282Y homozygote men had increased likelihoods of reporting chronic pain (odds ratio [OR] 1.23: 95% confidence interval [CI] 1.05-1.45, p = .01) and diagnoses of polymyalgia rheumatica, compared to common "wild-type" genotype. They were also more likely to have sarcopenia (OR 2.38: 1.80-3.13, p = 9.70 × 10-10) and frailty (OR 2.01: 1.45-2.80, p = 3.41 × 10-05). C282Y homozygote women (n = 312, 0.7%) aged 65-70 were more likely to be frail (OR 1.73: 1.05-2.84, p = .032) and have chronic knee, hip, and back pain. Overall, 1.50% of frail men and 1.51% of frail women in the 65-70 age group were C282Y homozygous.

CONCLUSIONS

HFE C282Y homozygosity is associated with substantial excess sarcopenia, frailty, and chronic pain at older ages. Given the availability of treatment, hereditary hemochromatosis is a strong candidate for precision medicine approaches to improve outcomes in late life.

Frailty, transition in frailty status and all-cause mortality in older adults of a Taichung community-based population

BACKGROUND

Previous studies have reported the associations of frailty phenotype or its components with mortality. However, studies that explored the effects of transition in frailty status on mortality were far less in Asian or Chinese. The aim of this study was to evaluate baseline frailty status and one-year change of frailty status in relation to all-cause mortality in Taiwanese community-dwelling older adults who participated in the Taichung Community Health Study for Elders.

METHODS

We conducted a community-based prospective cohort study. A total of 921 community-dwelling elderly men and women aged 65-99 years in Taichung City were enrolled in 2009-2010 and were followed up through 2016. We adopted the definition of frailty proposed by Fried et al., including five components: shrinking, weakness, poor endurance and energy, slowness, and low physical activity. Cox proportional hazards models were used to determine adjusted hazard ratios (HRs) of mortality with 95% confidence intervals (CIs) for frailty at baseline and one-year change in frailty status.

RESULTS

There were 160 deaths during the follow-up period. The mortality rates in groups of robust and frail were 20.26 and 84.66 per 1000 person-years respectively. After multivariate adjustment, the HR (CIs) for baseline frailty was 2.67 (1.73-4.12). Poor endurance and energy [1.88 (1.03-3.42)], slowness [2.60 (1.76-3.83)] and weakness [1.65 (1.16-2.33)] were found to be predictors of mortality. Increased risks in mortality for subgroups of robust-to-frail [2.76 (1.22-6.27)], frail-to-robust [3.87 (1.63, 9.19)], and frail-to-frail [4.08 (1.92-8.66)] over one-year period were observed compared with those remaining robust.

CONCLUSION

Baseline frailty status and one-year change in frailty status are associated with 6-year all-cause mortality among Taiwanese elderly adults. Frailty may be useful for identifying older adults at high risks for mortality prevention.

Current situation of frailty screening tools for older adults

Frailty is a geriatric syndrome associated with adverse outcomes such as falls, disability, and mortality. Frailty is common and contributes to rising health care costs. Early screening and timely tailored intervention may effectively prevent or delay the adverse outcomes in older adults. Studies on frailty and its specific measurement tools are increasing in number, but the debate on the screening instruments remains. Currently, self-reported screening tools can identify frailty and predict the risk of adverse outcomes in older adults. Because they are easy to use and quickly provide information, self-reported frailty screening tools have significant implication in primary care settings and clinics. We reviewed the frailty screening instruments in older adults and proposed a two-step pathway for frailty identification, and to manage declines in intrinsic capacity as well as boost resilience.