The Controversial Condition of Cognitive Frailty: What It Is, What It Should Be

Profiles of brain topology for dual-functional stability in old age

Dual-functional stability (DFS) in cognitive and physical abilities is important for successful aging. This study examines the brain topology profiles that underpin high DFS in older adults by testing two hypotheses: (1) older adults with high DFS would exhibit a unique brain organization that preserves their physical and cognitive functions across various tasks, and (2) any individuals with this distinct brain topology would consistently show high DFS. We analyzed two cohorts of cognitively and physically healthy older adults from the UK (Cam-CAN, n = 79) and the US (CF, n = 48) using neuroimaging data and a combination of cognitive and physical tasks. Variability in DFS was characterized using k-mean clustering for intra-individual variability (IIV) in cognitive and physical tasks. Graph theory analyses of diffusion tensor imaging connectomes were used to assess brain network segregation and integration through clustering coefficients (CCs) and shortest path lengths (PLs). Using support vector machine and regression, brain topology features, derived from PLs + CCs, differentiated the high DFS subgroup from low and mix DFS subgroups with accuracies of 65.82% and 84.78% in Cam-CAN and CF samples, respectively, which predicted cross-task DFS score in CF samples at 58.06% and 70.53% for cognitive and physical stability, respectively. Results showed distinctive neural correlates associated with high DFS, notably varying regional brain segregation and integration within critical areas such as the insula, frontal pole, and temporal pole. The identified brain topology profiles suggest a distinctive neural basis for DFS, a trait indicative of successful aging. These insights offer a foundation for future research to explore targeted interventions that could enhance cognitive and physical resilience in older adults, promoting a healthier and more functional lifespan.

Cognitive frailty in older adults: examining the impact of frailty criteria on neuropsychological profile, functional outcomes, activity levels, and quality of life

PURPOSE

Cognitive frailty (CF) is the co-existence of cognitive impairment and physical frailty without dementia, conferring greater risks of adverse clinical outcomes compared to either condition alone. However, the impact of physical frailty components on cognitive performance remains unclear. This study aims to evaluate CF by determining the neuropsychological profiles, functional outcomes, activity levels, and quality of life across the Fried Frailty Phenotype (FFP) and its components.

METHODS

Cross-sectional study involving 120 community-dwelling older adults without dementia, but with subjective cognitive complaints (SCC, defined as AD8 ≥ 1). Participants were stratified into three groups to assess CF: SCC-Robust, SCC-Prefrail, and SCC-Frail, and further categorized by individual FFP components. Cognitive performance was assessed by comparing neuropsychological test battery (NTB) Z-scores between CF and non-CF groups with Cohen's d for effect sizes. We performed linear regression to examine the relationships between both groups with NTB scores, Instrumental Activities of Daily Living (IADL), Frenchay Activities Index (FAI), and quality of life scores.

RESULTS

NTB scores showed no differences between individuals with CF when classified according to FFP criteria. Individuals with SCC-slow gait speed exhibited reduced processing speed (d = 0.62) and memory (d = 0.61); SCC-fatigue was associated with decreased working memory (d = 0.55). Regression analyses, adjusted for demographic and clinical variables, identified significant associations: slow gait speed with logical memory (- 0.42; 95% CI - 0.79 to - 0.038]) and symbol search (- 0.28; 95% CI - 0.56 to - 0.006]); fatigue with digit span backwards (- 0.66; 95% CI - 1.19 to - 0.14) and color trails 2 (- 0.67; 95% CI, - 1.15 to - 0.20). SCC-slow gait speed and SCC-fatigue were associated with reduced quality of life scores, but not with IADL and FAI scores.

CONCLUSION

Specific frailty components, notably slow gait speed and fatigue, influence cognitive function and quality of life. Our findings provide greater insights into characterizing CF. Further longitudinal studies are required to determine the cognitive and functional trajectories of CF.

Definition and assessment of psychological frailty in older adults: A scoping review

OBJECTIVES

The confusion surrounding psychological frailty and its components prompts the need for a standardized conceptual definition. To address this, we aimed to (1) identify the psychological variables included in multicomponent frailty assessment instruments used with older adults and examine their operationalization; and (2) formulate a thorough conceptualization of psychological frailty based on the variables identified.

METHODS

This study followed the most recent recommendations for conducting scoping reviews and is reported in accordance with PRISMA-ScR guidelines. We systematically searched the CINAHL, MEDLINE, PsycInfo, Scopus, and Web of Science databases, with additional searches in Google Scholar and reference lists.

RESULTS

Sixteen instruments were identified. The results suggested that: (1) In multicomponent frailty assessment instruments, psychological variables are poorly represented; (2) A wide variety of psychological variables are included in the instruments, the most frequent being cognitive functioning and affective functioning (e.g., depressive symptoms, emotional loneliness, anxiety symptoms, poor coping, and suicidal ideation); and (3) The way in which variables are referred to and operationalized varies across instruments.

CONCLUSIONS

Including both cognitive and affective variables in psychological frailty assessments may lead to inaccuracies. We suggest distinguishing between two separate dimensions within psychological frailty: cognitive frailty and affective frailty. A conceptual definition for each dimension is provided. This proposal aims to advance the debate regarding the conceptualization and assessment of psychological frailty, with further research and discussion needed to ensure its practical applicability.

Frailty and prefrailty phenotypes increase the odds of abnormal cognitive impairment screens in people with HIV

OBJECTIVE

Evaluate whether prefrail and frail people with HIV (PWH) have a higher risk of cognitive impairment on screens.

METHODS

Analysis of PWH aged 70 or older included in the ANRS EP66 SEPTAVIH cohort, on antiretroviral therapy for at least 12 months and with a MoCA test at enrolment. Adjusted risk of a Montreal Cognitive Assessment (MoCA) less than 26 was compared in frail/prefrail versus robust PWH.

RESULTS

A total of 503 PWH were enrolled with a median age of 73 years, IQR [71-77], 81.5% were male, 73.8% were French natives, 32.9% had low socio-economic status (EPICES score >30.2), and 41.3% were college graduates; 27.3% had a history of clinical AIDS. A total of 294 (58.5%) PWH had a MoCA score less than 26; 182 (36%) a MoCA score 23 or less. Frailty, prefrailty and robustness were found in 13.1, 63.6 and 23.3% participants, respectively. PWH with a MoCA less than 26 had a significantly higher risk of being frail/prefrail, this before [odds ratio (OR) = 2.31; 95% confidence interval (CI) 1.50-3.57], and after adjustment for confounders (OR = 1.80; 95% CI 1.07-3.01). The risk of being frail/prefrail in patients with a MoCA 23 or less was higher (adjusted OR = 2.75; 95% CI 1.46-5.16). Other factors independently associated with a MoCA less than 26 were older age, birth outside of France and a lower education level and being diabetic.

CONCLUSION

Abnormal MoCA screens were frequent in our cohort of PWH aged 70 or older with controlled HIV disease. Cognitive impairment should be systematically screened in frail/prefrail PWH. Frailty/prefrailty, diabetes and social factors, but not HIV-related factors, are important determinants of cognitive function in PWH with controlled disease.

Navigating and diagnosing cognitive frailty in research and clinical domains

While physical frailty has been recognized as a clinical entity for some time, the concept of cognitive frailty (CF) is now gaining increasing attention in the geriatrics research community. CF refers to the co-occurrence of physical frailty and cognitive impairment in older adults, which has been suggested as a potential precursor to both dementia and adverse physical outcomes. However, this condition represents a challenge for researchers and clinicians, as there remains a lack of consensus regarding the definition and diagnostic criteria for CF, which has limited its utility. Here, using insights from both the physical frailty literature and cognitive science research, we describe emerging research on CF. We highlight areas of agreement as well as areas of confusion and remaining knowledge gaps, and provide our perspective on fine-tuning the current construct, aiming to stimulate further discussion in this developing field.

Development and validation of a nomogram-assisted tool to predict potentially reversible cognitive frailty in Chinese community-living older adults

BACKGROUND

Cognitive frailty (CF) is a complex and heterogeneous clinical syndrome that indicates the onset of neurodegenerative processes and poor prognosis. In order to prevent the occurrence and development of CF in real world, we intended to develop and validate a simple and timely diagnostic instrument based on comprehensive geriatric assessment that will identify patients with potentially reversible CF (PRCF).

METHODS

750 community-dwelling individuals aged over 60 years were randomly allocated to either a training or validation set at a 4:1 ratio. We used the operator regression model offering the least absolute data dimension shrinkage and feature selection among candidate predictors. PRCF was defined as the presence of physical pre-frailty, frailty, and mild cognitive impairment (MCI) occurring simultaneously. Multivariate logistic regression was conducted to build a diagnostic tool to present data as a nomogram. The performance of the tool was assessed with respect to its calibration, discrimination, and clinical usefulness.

RESULTS

PRCF was observed in 326 patients (43%). Predictors in the tool were educational background, coronary heart disease, handgrip strength, gait speed, instrumental activity of daily living (IADL) disability, subjective cognitive decline (SCD) and five-times-sit-to-stand test. The diagnostic nomogram-assisted tool exhibited good calibration and discrimination with a C-index of 0.805 and a higher C-index of 0.845 in internal validation. The calibration plots demonstrated strong agreement in both the training and validation sets, while decision curve analysis confirmed the nomogram's efficacy in clinical practice.

CONCLUSIONS

This tool can effectively identify older adults at high risk for PRCF, enabling physicians to make informed clinical decisions and implement proper patient-centered individual interventions.

The effects of interventions to enhance cognitive and physical functions in older people with cognitive frailty: a systematic review and meta-analysis

INTRODUCTION

Cognitive frailty is the co-existence of mild cognitive impairment and physical frailty that increases the risk of adverse health outcomes. The existing systematic reviews on cognitive frailty in the literature have focused only on identifying associated factors and adverse outcomes, and their relationship with frailty and cognition. This study aimed to examine the effects of interventions on cognitive functions, frailty, and physical functions and provide an overview of intervention components used in older people with cognitive frailty.

METHODS

This is a systematic review and meta-analysis. Medline, PubMed, CINAHL, Embase, PsycINFO, and Cochrane were searched for publishing during 2013-2021. Studies were selected based on the following eligibility criteria: 1) older people (age ≥ 60 years), 2) cognitive frailty, 3) outcomes on frailty or cognition or physical function, and 4) randomized controlled trial with any type of intervention. The Physiotherapy Evidence Database (PEDro) scale was used to rate the quality of the included studies. The review protocol was registered with PROSPERO (CRD42021251321).

RESULTS

Two thousand five hundred six studies were identified, 9 were eligible, and 8 were included in the meta-analysis. The standardized mean difference (Hedges G) between groups of cognitive functions was 0.95, frailty status was 0, physical function in walking was -1.67, and the physical function in core strength assessment was 3.39. Physical activity appeared as an essential component in all interventions for older people with cognitive frailty.

DISCUSSION

All interventions include physical activity as one of the components. Other components include cognitive training, nutrition education, behavioural intervention, mind-body intervention, psychosocial support, and virtual reality. The interventions are effective to promote cognitive and physical functions, but not physical frailty.

A systematic review and meta-analysis on cognitive frailty in community-dwelling older adults: risk and associated factors

OBJECTIVES

To identify which factors are associated with cognitive frailty (CF), as well as the impact of CF on the incidence of dementia and mortality.

METHODS

A systematic review with meta-analysis was carried out using papers that enrolled a total of 75,379 participants and were published up to January 2020.

RESULTS

Of the 558 identified records, 28 studies met the inclusion criteria and were included in the review. The meta-analysis of cross-sectional studies showed that CF has a significant association of having an older age and a history of falls. In longitudinal studies, the analysis showed a significant increase in risk of mortality and dementia for those with CF.

DISCUSSION

This is the first systematic review and meta-analysis on CF, which addressed a wide variety of factors associated with the theme and which pointed out some as a potential target for prevention or management with different interventions or treatments, showing the clinical importance of its identification in the most vulnerable and susceptible groups.

Pre-Existing Frailty is Unrelated to Progression of Diffuse Subcortical Damage of Vascular Origin: A Longitudinal Prospective Study in Community-Dwelling Older Adults

Background:

Both frailty and white matter hyperintensities (WMH) of presumed vascular origin are associated with enhanced expression of inflammatory biomarkers. Therefore, it is possible that pre-existing frailty predisposes to WMH progression. However, this relationship has not been explored. This population-based longitudinal prospective study aimed to assess the impact of frailty on subsequent progression of WMH in community-dwelling older adults living in rural Ecuador.

Methods:

Participants of the Atahualpa Project Cohort received baseline frailty assessment and brain MRIs. Frailty was evaluated by means of the Edmonton Frail Scale (EFS). WMH were graded according to the modified Fazekas scale. Individuals who received a follow-up brain MRI were included. Poisson regression models were fitted to assess the differential rate of WMH progression according to EFS score, after adjusting for demographics, level of education, and cardiovascular risk factors.

Results:

The study included 263 individuals aged ≥60 years (mean age: 65.7 ± 6.2 years; 57% women). The mean EFS score at baseline was 4 ± 2.3 points. Follow-up MRIs after a median follow-up of 6.5 years showed WMH progression in 103 (39%) individuals. The EFS score at baseline was associated with WMH progression in unadjusted analysis (P = .006). However, significance was not achieved in a multivariate Poisson regression model adjusted for relevant covariates (IRR: 1.07; 95% C.I.: 0.97-1.18; P = .192).

Conclusions:

Study results do not support an independent relationship between frailty and WMH progression, adjusting for the confounding effect of aging.

Cognitive dysfunction correlates with physical impairment in frail patients with acute myocardial infarction

BACKGROUND

To the best of our knowledge, the association of physical impairment and cognitive decline has never been investigated in frail patients with acute myocardial infarction.

AIM

The aim of our study is to assess the correlation between physical and cognitive dysfunction in frail patients with ST-elevation myocardial infarction (STEMI).

METHODS

We examined consecutive frail patients with first STEMI treated with primary percutaneous coronary intervention (PPCI). All patients were evaluated via Mini Mental State Examination (MMSE) and 5-m gait speed test after PPCI.

RESULTS

A total of 871 frail patients with suspected STEMI were admitted and 301 patients successfully completed the study. We found that the gait speed significantly correlated with the MMSE score (r: 0.771; p: < 0.001). The independent effects on MMSE score were confirmed in a linear multivariate analysis.

CONCLUSIONS

Taken together, our findings indicate that an assessment of both cognitive and physical conditions should be included in the comprehensive geriatric evaluation of hospitalized older STEMI patients.

An update on cognitive frailty: Its definition, impact, associated factors and underlying mechanisms, and interventions

Since the concept and operational definition of "cognitive frailty" (simultaneous presence of physical frailty and cognitive impairment without concurrent dementia) were proposed by the International Academy of Nutrition and Aging and the International Association of Gerontology and Geriatrics, cognitive frailty has been widely investigated. This review is intended to address the operational definition of cognitive frailty, its consequences, contributing factors and underlying mechanisms, as well as interventions for cognitive frailty. Although the definitions and assessments of cognitive frailty vary among researchers, older adults with both physical frailty and cognitive impairment are shown to be at higher risk of adverse health outcomes, including death, disability, hospitalization and incident dementia, than those with either condition alone. While the underlying mechanisms of cognitive frailty are still unclear, factors shown to be associated with cognitive frailty include sociodemographic factors, social status, nutritional status, geriatric syndrome, physical and cognitive activities, functional status, comorbidities, medication use, gut-derived metabolites and structural changes in the brain. Accumulating evidence indicates the need for comprehensive geriatric assessment that helps identify the possible causes of cognitive frailty and develop a multimodal individualized intervention to prevent adverse health outcomes for older adults with cognitive frailty. Further studies are required to clarify the mechanisms through which physical frailty and cognitive impairment interact to accelerate adverse health outcomes, particularly cognitive outcomes. In addition, for older adults with cognitive frailty, an effective flow diagram from primary screening through comprehensive assessment to multidimensional intervention needs to be developed for future implementation in both clinical and community settings. Geriatr Gerontol Int 2021; ••: ••-••.

Motoric cognitive risk syndrome, physio-cognitive decline syndrome, cognitive frailty and reversibility with dual-task exercise

INTRODUCTION

Cognitive frailty (CF) is associated with dementia and disability. It was initially proposed in 2013 by the International Institute of Nutrition and Aging and the International Geriatrics Association. Over the years, there have been many emerging definitions e.g., Motoric Cognitive Risk Syndrome (MCR), Physio-cognitive Decline Syndrome (PCDS), reversible CF and potentially reversible CF.

OBJECTIVE

Our objective was to determine the demographics including physical, functional, and psychosocial factors for the four CF definitions amongst community-dwelling older adults. In addition, the effect of dual-task exercise on the reversibility of different definitions of CF was also studied.

METHODS

Participants were community-dwelling older adults aged ≥60 years recruited between August 2017 and December 2019. Older adults screened to be frail, prefrail or have cognitive impairment were invited to participate in dual-task exercise program called HAPPY (Healthy Ageing Promotion Program for You). Improvement in cognition, frailty, and physical performance after a 3-month dual-task exercise intervention program was compared with controls.

RESULTS

The prevalence of CF depending on definition ranged from 8.8% to 28.7% with minimal overlap. The cognitive scores were significantly lower in all the groups predominantly affecting non-memory domains except for reversible CF. Frailty was three to seven times more prevalent in CF. MCR group had higher prevalence of functional limitation, pain and depression. All four groups had significant increase in global cognition scores especially in the attention domain where the control group declined, and reduction in the prevalence of frailty post intervention. MCR and reversible CF were significantly associated with increased odds of cognitive improvement after 3 months of intervention compared with control.

CONCLUSION

CF is a novel concept and regardless of the definitions, is a target for reversing frailty, functional limitation and cognitive impairment through dual-task exercise. Long-term prospective studies are needed to evaluate the effectiveness of dual-task interventions in delaying the conversion to dementia and reduction of disability.

ADAM10: Biomarker of mild cognitive impairment but not of cognitive frailty

Mild cognitive impairment (MCI) associated with physical frailty gave rise to the new concept of cognitive frailty. Previous studies have suggested that MCI may represent a condition that precedes Alzheimer's disease (AD), in view of its higher conversion rate to dementia, when compared with the conversion rate of cognitively healthy older adults. Therefore, and considering that MCI represents a reversible condition, the identification of biomarkers for this condition is imperative to early diagnosis. Accordingly, this study aimed to assess whether the platelet and plasma levels of ADAM10 could be related with the concomitant conditions of MCI and physical frailty, in order to support a new blood-based biomarker for the construct of cognitive frailty. Sixty-one adults aged 60 years or older participated in this study. The results showed that ADAM10 levels are reduced in platelets (p < 0.05) and increased in plasma (p < 0.05) of older adults with MCI compared to healthy controls, regardless of the physical frailty condition. The analysis of the ROC curve of ADAM10 in platelets showed sensitivity and specificity of 72.7 and 73.9%, respectively, to correct differentiate between participants with preserved cognition from those with MCI. For plasma samples, ADAM10 presented 62.5 and 90.0%, sensitivity and specificity respectively, to differentiate the aforementioned conditions. Together with other clinical criteria blood ADAM10 could be a relevant, low-invasive, low-cost and fast processing biomarker tool to help in the early and accurate diagnosis of MCI, however this marker was not able to identify cognitive frailty.

Effects of physical exercise on the cognition of older adults with frailty syndrome: A systematic review and meta-analysis of randomized trials

OBJECTIVES

To analyze the effects of physical exercise on the cognition of community-dwelling older adults with frailty syndrome, through randomized clinical trials.

DATA SOURCES

Articles published until March 2020 were searched in the databases Science Direct, Scopus, Web of Science, PubMed, Lilacs, Cochrane, IEEE, EMBASE, and SciELO. Search terms included frailty, aged, exercise, rehabilitation, and cognition. For the Portuguese language, equivalent terms were used.

STUDY SELECTION

Only randomized clinical trials that used physical exercise as an intervention method in community-dwelling older adults (≥ 60y.) with frailty syndrome, and which performed cognitive assessments before and after the intervention were included.

DATA EXTRACTION

Two authors performed data extraction using predefined data fields. The risk of bias of the six included studies was assessed using the PEDro scale.

DATA SYNTHESIS

In total, 4501 studies were found. After the selection process, 6 studies were included in the systematic review and 4 studies in the meta-analysis, all with a low risk of bias. The studies included 655 community-dwelling older adults with frailty syndrome. The types of intervention varied, with multicomponent physical exercise being the most frequent. The cognitive assessments were diverse, and the Mini-mental State Examination, Trail Making Test forms A and B, and Digit Span test were the most frequently applied. A meta-analysis was performed with Global Cognition and Trail Making Test forms A and B. The data from the meta-analysis showed that physical exercise improves Global Cognition (Mean Difference = 2.26; 95% CI, 0.42 - 4.09; P = 0.02) and mental flexibility (Trail Making Test B) (Mean Difference = -30.45; 95% CI; - 47.72 - -13.19; P = 0.0005).

CONCLUSION

Interventions with physical exercise promote benefits in global cognition and mental flexibility of older adults with frailty syndrome.

CCCDTD5: Reducing the risk of later-life dementia. Evidence informing the Fifth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD-5)

The Fifth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD-5) was a year-long process to synthesize the best available evidence on several topics. Our group undertook evaluation of risk reduction, in eight domains: nutrition; physical activity; hearing; sleep; cognitive training and stimulation; social engagement and education; frailty; and medications. Here we describe the rationale for the undertaking and summarize the background evidence-this is also tabulated in the Appendix. We further comment specifically on the relationship between age and dementia, and offer some suggestions for how reducing the risk of dementia in the seventh decade and beyond might be considered if we are to improve prospects for prevention in the near term. We draw to attention that a well-specified model of success in dementia prevention need not equate to the elimination of cognitive impairment in late life.

Pulmonary and Extra-Pulmonary Clinical Manifestations of COVID-19

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been recently identified as the culprit of the highly infectious, outbreak named coronavirus disease 2019 (COVID-19) in China. Now declared a public health emergency, this pandemic is present in more than 200 countries with over 14 million cases and 600,000 deaths as of July 18, 2020. Primarily transmitted through the respiratory tract, the most common clinical presentations of symptomatic individuals infected with SARS-CoV-2 include fever, dyspnea, cough, fatigue, and sore throat. In advanced cases, patients may rapidly develop respiratory failure with acute respiratory distress syndrome, and even progress to death. While it is known that COVID-19 manifests similarly to the 2003 Severe Acute Respiratory Syndrome (SARS) and the 2012 Middle East Respiratory Syndrome (MERS), primarily affecting the pulmonary system, the impact of the disease extends far beyond the respiratory system and affects other organs of the body. The literature regarding the extrapulmonary manifestations (cardiovascular, renal, hepatic, gastrointestinal, ocular, dermatologic, and neurological) of COVID-19 is scant. Herein, we provide a comprehensive review of the organ-specific clinical manifestations of COVID-19, to increase awareness about the various organs affected by SARS-CoV-2 and to provide a brief insight into the similarities and differences in the clinical manifestations of COVID-19 and the earlier SARS and MERS.