Accumulation of health disorders as a systemic measure of aging: Findings from the NLTCS data

Complete dentures associated with frailty among edentulous older Japanese people: A prospective analysis

OBJECTIVE

This study aimed to explore the cross-sectional and prospective associations between self-reported functionality of complete dentures (FCD), satisfaction with complete dentures (SCD) and the ability to chew hard food (ACHF) on the one hand and the frailty index (FI) on the other hand among edentulous community-dwelling older Japanese people.

METHODS

The study examined 770 edentulous participants of the Nihon University Japanese Longitudinal Study of Aging. The self-reported FCD, SCD and ability to chew six groups of food (from hardest to softest) with complete dentures were the independent variables at the baseline. The FI was computed including 40 deficits as the dependent variable at the baseline and 4 years later. Cross-sectional and prospective generalized linear regression models were fitted controlling for age, gender, marital status, education, working status and area of residence.

RESULTS

The use of non-functional complete dentures and dissatisfaction with complete dentures were both associated with a higher FI cross-sectionally (3.9% [95% CI 2.2-5.6] and 3.2% [95% CI 1.5-4.9], respectively) and prospectively (3.9% [95% CI 2.0-6.0] and 3.3% [95% CI 1.3-5.3], respectively). Regarding the ability to chew, a higher FI at baseline was observed among those able to chew food of Group 2 (1.9%, [95% CI 0.1-3.7]) and Groups 4-6 (1.9%, [95% CI 0.1-3.7]), and a progressive increment in the FI, as the participants reported being able to chew softer groups of food at the follow-up (Group 2: 2.2% [95% CI 0.05-4.3]; Group 3: 3.6% [95% CI 1.2-6.0]; and Groups 4-6: 3.4 [95% CI 0.7-6.1]).

CONCLUSION

Self-reported use of non-functional complete dentures, dissatisfaction with dentures and a reduced ACHF with complete dentures were associated with a higher FI both cross-sectionally and prospectively.

Mortality burden from variation in provision of surgical care in emergency general surgery: a cohort study using the National Inpatient Sample

Background

The decision to undertake a surgical intervention for an emergency general surgery (EGS) condition (appendicitis, diverticulitis, cholecystitis, hernia, peptic ulcer, bowel obstruction, ischemic bowel) involves a complex consideration of factors, particularly in older adults. We hypothesized that identifying variability in the application of operative management could highlight a potential pathway to improve patient survival and outcomes.

Methods

We included adults aged 65+ years with an EGS condition from the 2016-2017 National Inpatient Sample. Operative management was determined from procedure codes. Each patient was assigned a propensity score (PS) for the likelihood of undergoing an operation, modeled from patient and hospital factors: EGS diagnosis, age, gender, race, presence of shock, comorbidities, and hospital EGS volumes. Low and high probability for surgery was defined using a PS cut-off of 0.5. We identified two model-concordant groups (no surgery-low probability, surgery-high probability) and two model-discordant groups (no surgery-high probability, surgery-low probability). Logistic regression estimated the adjusted OR (AOR) of in-hospital mortality for each group.

Results

Of 375 546 admissions, 21.2% underwent surgery. Model-discordant care occurred in 14.6%; 5.9% had no surgery despite a high PS and 8.7% received surgery with low PS. In the adjusted regression, model-discordant care was associated with significantly increased mortality: no surgery-high probability AOR 2.06 (1.86 to 2.27), surgery-low probability AOR 1.57 (1.49 to 1.65). Model-concordant care showed a protective effect against mortality (AOR 0.83, 0.74 to 0.92).

Conclusions

Nearly one in seven EGS patients received model-discordant care, which was associated with higher mortality. Our study suggests that streamlined treatment protocols can be applied in EGS patients as a means to save lives.

Level of evidence

III.

Age-dependent change and intraskeletal variability in secondary osteons of elderly Australians

There is a need to fully understand intra-skeletal variability within different populations to develop and improve age-at-death estimation methods. This study evaluates age-related histomorphometric changes in three different bones intra-individually in a modern Australian sample. Four female and 13 male elderly Australian adult donors (67-93 years) were examined for osteon population density (OPD), osteon area (On.Ar), and Haversian canal area (H.Ar) of secondary osteons to compare between femora, ribs, and humeri and assess against age. In the pooled sex sample, no statistically significant correlations were observed between age and each histological variable. In the males, OPD of the femur increased significantly with age, as did porosity in the rib. In the male humeri, OPD increased moderately with age, while H.Ar was decreased moderately with age. Intra-bone comparisons showed that males had significantly higher osteon counts in their ribs compared to their femora, while their ribs showed statistically significantly less porosity than their humeri. When bone size was accounted for, by adjusting the femur and humerus histology data by robusticity indices, histology values were found to be similar between bones within the same individual. This is despite the upper and lower limbs receiving different ranges and types of biomechanical load. Our findings demonstrate that bone size influences histomorphometry, and this could confound age-at-death estimations that have not been adjusted for robusticity. Future studies would benefit from examining bone histomorphometry within a larger sample size and incorporating bone robusticity measures into histology analyses.

Associations of Dietary Diversity Trajectories with Frailty among Chinese Older Adults: A Latent Class Trajectory Analysis Based on a CLHLS Cohort

BACKGROUND

High dietary diversity has been found to be associated with frailty. However, the trajectory of dietary diversity intake in relation to frailty is unclear.

METHODS

Using the latent class trajectory modeling approach, we identified distinctive dietary variety trajectory groups among 2017 participants based on the Chinese Longitudinal Healthy Longevity Survey acquired at four time points within a 10-year period. Frailty status was assessed using a frailty index comprising 37 health deficits. Dietary diversity was quantified using the dietary variety score (DVS), based on food category consumption frequency. Logistic regression analyses were employed to explore the association between DVS change trajectories and frailty.

RESULTS

This study identified two distinct DVS trajectories: "Moderate-Slow decline-Slow growth", encompassing 810 (40.16%) individuals, and "Moderate-Slow growth-Accelerated decline", including 1207 (59.84%) individuals. After adjusting for covariates, the odds ratio for DVS in the "Moderate-Slow decline-Slow growth" group was 1.326 (95% confidence interval: 1.075-1.636) compared to the "Moderate-Slow growth-Accelerated decline" group. The "Moderate-Slow decline-Slow growth" trajectory continued to decrease and was maintained at a low level in the early stages of aging.

CONCLUSION

Sustaining a high dietary diversity trajectory over time, particularly in the early stages of aging, could potentially decrease the risk of frailty among older Chinese adults.

Longitudinal Patterns of Multimorbidity in Gulf War Era Veterans With and Without Gulf War Illness

Objectives: To examine whether severe Gulf War illness (SGWI) case status was associated with longitudinal multimorbidity patterns. Methods: Participants were users of the Veteran Health Administration Health Care System drawn from the Gulf War Era Cohort and Biorepository (n = 840). Longitudinal measures of multimorbidity were constructed using (1) electronic health records (Charlson Comorbidity Index; Elixhauser; and Veterans Affairs Frailty Index) from 10/1/1999 to 6/30/2023 and (2) self-reported medical conditions (Deficit Accumulation Index) since the war until the survey date. Accelerated failure time models examined SGWI case status as a predictor of time until threshold level of multimorbidity was reached, adjusted for age and sociodemographic and military characteristics. Results: Models, adjusted for covariates, revealed that (1) relative to the SWGI- group, the SGWI+ group was associated with an accelerated time for reaching each threshold and (2) the relationship between SGWI and each threshold was not moderated by age. Discussion: Findings suggest that veterans with SGWI experienced accelerated aging.

[Association Between Socioeconomic Status, Productive Aging, and Frailty Index in Urban Elderly Population in China]

Objective

To explore the impact of socioeconomic status and productive aging on the frailty index of urban elderly population in China, and to provide reference for improving their health level.

Methods

We obtained data from the 2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS) and included 1890 urban elderly people aged 60 and over in the study. Multiple linear regression model was used to analyze the influencing factors of the productive aging and the frailty index of the urban elderly population in China. A structural equation model was constructed to explore the relationship between socioeconomic status, productive aging, and frailty index.

Results

Elderly people with high socioeconomic status ( β=0.082, P<0.001) had higher level of productive aging. Elderly people with high socioeconomic status ( β=－0.091, P<0.001) and high level of productive aging ( β=－0.330, P<0.001) had lower frailty index. Productive aging played an intermediary role ( β=－0.259, 95% CI: －0.380--0.181) between socioeconomic status and frailty index.

Conclusion

The socioeconomic status and productive aging of the elderly people are important predictors of their frailty index. The government should exert its leadership functions to encourage the elderly, especially those with low education and income levels, to actively learn knowledge and skills, and to provide support for the elderly to participate in productive activities.

How Neighborhood Structural and Individual Characteristics Affect Frailty Progression: Evidence from the China Health and Retirement Longitudinal Study

OBJECTIVES

(1) To characterize the average trajectories of frailty over time in Chinese community-dwelling older adults; (2) To assess the effects of neighborhood structural and individual characteristics on frailty progression.

DESIGN

A nationally representative prospective cohort study.

SETTING

Communities in 28 provinces, China.

PARTICIPANTS

6238 respondents aged 60 and above in 447 communities from four waves of the China Health and Retirement Longitudinal Study.

MEASUREMENTS

Frailty was measured using the 61-item Frailty Index (FI).

RESULTS

The trajectory of FI was nonlinear, with an average growth rate of 0.025 that significantly slows down at the rate of 0.002 per year. Older, male, and uninsured respondents showed faster rates of growth in FI over time than younger, female, and insured counterparts. Respondents living in neighborhoods with a higher percentage of the older population and rural villages showed slower rates of growth in FI over time.

CONCLUSION

Expanding health insurance coverage and keeping a high clustering of the elderly in neighborhoods may be the potential strategies for population-level frailty prevention and interventions.

Heath status, frailty, and multimorbidity in patients with emergency general surgery conditions

BACKGROUND

Although nearly 1 million older adults are admitted for emergency general surgery conditions yearly, the extent to which baseline health influences the development and treatment of emergency general surgery conditions is unknown. We evaluated baseline health and older patients with and without emergency general surgery conditions.

METHODS

We used the prospectively collected Medicare Current Beneficiary Survey with Medicare claims and 2 validated health frameworks: (1) Deficit Accumulation Frailty Score and (2) Complex Multimorbidity. Self-reported health and function items were used to derive pre-emergency general surgery conditions Deficit Accumulation Frailty Score and Complex Multimorbidity scores. Deficit Accumulation Frailty Score ranges from 0 (no frailty deficits) to 100 (all possible deficits present). Complex Multimorbidity is a 3-point categorical rank based on the presence of chronic conditions, functional limitations, and geriatric syndromes. Specific survey factors were also examined to determine association with development of emergency general surgery conditions or use of operative management.

RESULTS

Of 54,417 individuals, 1,960 had emergency general surgery conditions (median age 79 [interquartile range 73-84]). Patients with emergency general surgery conditions had significantly higher Deficit Accumulation Frailty Score (19 [interquartile range 11-31] vs 14 [8-24]) and were more likely to be in the most severe Complex Multimorbidity category (38% vs 29%). Emergency general surgery conditions patients had higher proportions of nearly every health category, with the most striking differences in functional limitations. Patients who were treated nonoperatively had the poorest overall baseline health.

CONCLUSION

Patients who developed emergency general surgery conditions had more severe health burden than patients who did not, particularly in functional status. Clinicians must better understand the interaction between baseline health vulnerability and emergency surgical disease to improve prognostication and ensure alignment of patient goals and treatment strategies.

Social engagement and physical frailty in later life: does marital status matter?

BACKGROUND

Physical frailty is a common characteristic of older people with the ageing process and has been viewed as a major public health issue. The longitudinal association between different social engagement and physical frailty among older people has not been explored adequately in China. Marital status forms a critical context for the link between social engagement and frailty among older people, which might constitute a moderating process. The purpose of the present study is to investigate the longitudinal association between social engagement and the changes in physical frailty among Chinese older adults, and to examine whether the association between social engagement and frailty differs by marital status.

METHODS

The data use in this study were from the data from the China Health and Retirement Longitudinal Study aged 60+ years from 2011 to 2015. A total of 6575 respondents who participated in at least one follow-up wave were included in the analysis. The relationship between social engagement and changes in frailty over time, and the moderating role of marital status were estimated using individual fixed-effects models. Sensitive analyses were conducted to test the robustness of the results.

RESULTS

After adjusting the confounders, participants who interact with friends (Coef: -1.309, P < 0.001), engaging in hobby groups (Coef: -1.189, P < 0.001), engaging in sports groups (Coef: -0.945, P = 0.001), and volunteering (Coef: -1.957, P = 0.001) with a frequency of almost daily had a significantly lower frailty risk than participants who never engaging in those activities. The association between frequent engaging in hobby groups and physical frailty was strongest for unmarried than married older adults (Coef: -1.325, P = 0.031).

CONCLUSIONS

Frequent social engagement might help to decrease the risk of frailty in the Chinese older population. This finding has important implications for public health policy and encourages the incorporation of a broad range of social engagement into the daily lives of older individuals. Specially, encouraging unmarried older adults to engage in intellectual activities, such as playing chess or Mahjong with others, may be an effective way to reduce physical frailty.

Development of a Preoperative Adult Spinal Deformity Comorbidity Score That Correlates With Common Quality and Value Metrics: Length of Stay, Major Complications, and Patient-Reported Outcomes

STUDY DESIGN

Retrospective review of a multicenter prospective registry.

OBJECTIVES

Our goal was to develop a method to risk-stratify adult spinal deformity (ASD) patients on the basis of their accumulated health deficits. We developed a novel comorbidity score (CS) specific to patients with ASD based on their preoperative health state and investigated whether it was associated with major complications, length of hospital stay (LOS), and self-reported outcomes after ASD surgery.

METHODS

We identified 273 operatively treated ASD patients with 2-year follow-up. We assessed associations between major complications and age, comorbidities, Charlson Comorbidity Index score, and Oswestry Disability Index score. Significant factors were used to construct the ASD-CS. Associations of ASD-CS with major complications, LOS, and patient-reported outcomes were analyzed.

RESULTS

Major complications increased significantly with ASD-CS (P < .01). Compared with patients with ASD-CS of 0, the odds of major complications were 2.8-fold higher (P = .068) in patients with ASD-CS of 1 through 3; 4.5-fold higher (P < .01) in patients with ASD-CS of 4 through 6; and 7.5-fold higher (P < .01) in patients with ASD-CS of 7 or 8. Patients with ASD-CS of 7 or 8 had the longest mean LOS (10.7 days) and worst mean Scoliosis Research Society-22r total score at baseline; however, they experienced the greatest mean improvement (0.98 points) over 2 years.

CONCLUSIONS

The ASD-CS is significantly associated with major complications, LOS, and patient-reported outcomes in operatively treated ASD patients.

Dynamic statistical model for predicting the risk of death among older Chinese people, using longitudinal repeated measures of the frailty index: a prospective cohort study

BACKGROUND

Frailty is a common characteristic of older people with the ageing process. We aimed to develop and validate a dynamic statistical prediction model to calculate the risk of death in people aged ≥65 years, using a longitudinal frailty index (FI).

METHODS

One training dataset and three validation datasets from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) were used in our study. The training dataset and validation datasets 1 to 3 included data from 9,748, 7,459, 9,093 and 6,368 individuals, respectively. We used 35 health deficits to construct the FI and a longitudinal FI based on repeated measurement of FI at every wave of the CLHLS. A joint model was used to build a dynamic prediction model considering both baseline covariates and the longitudinal FI. Areas under time-dependent receiver operating characteristic curves (AUCs) and calibration curves were employed to assess the predictive performance of the model.

RESULTS

A linear mixed-effects model used time, sex, residence (city, town, or rural), living alone, smoking and alcohol consumption to calculate a subject-specific longitudinal FI. The dynamic prediction model was built using the longitudinal FI, age, residence, sex and an FI-age interaction term. The AUCs ranged from 0.64 to 0.84, and both the AUCs and the calibration curves showed good predictive ability.

CONCLUSIONS

We developed a dynamic prediction model that was able to update predictions of the risk of death as updated measurements of FI became available. This model could be used to estimate the risk of death in individuals aged >65 years.

Frailty Index and Sex-Specific 6-Year Mortality in Community-Dwelling Older People: The ActiFE Study

BACKGROUND

Considering that mortality rate and deficit accumulation varies considerably in men and women, we performed a sex-stratified analysis of the association between an estimated frailty index (eFI) with 6-year mortality in the Activity and Function in the Elderly (ActiFE) Study.

METHODS

We constructed an eFI using a score (0 [no deficit] to 1 [deficit]) from 32 baseline items representing multiple domains. eFI represents the sum of all scores divided by 32. Cox proportional hazards models adjusted for age, smoking, alcohol intake, and education were used to evaluate this association.

RESULTS

Among 1,204 participants (57.5% men), 18.5% men and 26.0% women were frail (eFI ≥ 0.2) with an age-adjusted mean eFI of 0.13 (95% confidence interval [CI] 0.12, 0.13) and 0.15 (95% CI 0.15, 0.16), respectively. Mortality rate in men (146 deaths) was 34.4 (95% CI 29.3, 40.5) and in women (50 deaths) 15.1 (95% CI 11.5, 19.9) per 1,000 person-years. A 0.1 increment of eFI was associated with a hazard ratio (HR) of 1.94 (95% CI 1.60, 2.35) in men and 2.06 (95% CI 1.58, 2.69) in women. Frail versus nonfrail men and women had a HR of 2.46 (95% CI 1.74, 3.48), and 2.98 (95% CI 1.55, 5.70), respectively. We detected sex differences in the order of the eight common contributor items to the eFI.

CONCLUSIONS

We observed a statistically significant difference for the age-adjusted eFI and the frailty prevalence in men and women. However, our analysis does not suggest the presence of effect modification by sex in the association with mortality.

Residential Greenness and Frailty Among Older Adults: A Longitudinal Cohort in China

OBJECTIVES

Frailty is an accumulation of deficits characterized by reduced resilience to stressors and increased vulnerability to adverse outcomes. There is evolving evidence on the health benefits of residential greenness, but little is known about its impact on frailty.

DESIGN

A longitudinal cohort study.

SETTING AND PARTICIPANTS

We included older adults aged ≥65 years from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) with a 12-year follow-up.

METHODS

We assessed residential greenness by calculating the Normalized Difference Vegetation Index (NDVI) in the 500 m radius around participants' residence. We used 39 self-reported health items to construct a frailty index (FI) as a proportion of accumulated deficits. We defined an FI of ≤0.21 as nonfrail and prefrail, and an FI of >0.21 as frail. We used the mixed effects logistic regression models to examine the association between residential greenness and frailty, adjusted for a number of covariates.

RESULTS

We had 16,238 participants, with a mean age of 83.0 years (standard deviation: 11.5). The mean baseline NDVI and FI were 0.40, and 0.12, respectively. Compared to the participants living in the lowest quartile of residential greenness, those in the highest quartile had a 14% [odds ratio (OR): 0.86, 95% confidence interval (CI): 0.77, 0.97] lower odds of frailty. The association was stronger among urban vs rural residents. Additionally, each 0.1-unit increase in annual average NDVI was related to a 2% higher odds of improvement in the frailty status (OR: 1.02, 95% CI: 1.00, 1.04).

CONCLUSIONS AND IMPLICATIONS

Our study suggests that higher levels of residential greenness are related to a lower likelihood of frailty, specifically in urban areas.

Polygenic risk score for disability and insights into disability-related molecular mechanisms

Late life disability is a highly devastating condition affecting 20% or more of persons aged 65 years and older in the USA; it is an important determinant of acute medical and long-term care costs which represent a growing burden on national economies. Disability is a multifactorial trait that contributes substantially to decline of health/wellbeing. Accordingly, gaining insights into the genetics of disability could help in identifying molecular mechanisms of this devastating condition and age-related processes contributing to a large fraction of specific geriatric conditions, concordantly with geroscience. We performed a genome-wide association study of disability in a sample of 24,068 subjects from five studies with 12,550 disabled individuals. We identified 30 promising disability-associated polymorphisms in 19 loci at p < 10^-4; four of them attained suggestive significance, p < 10^-5. In contrast, polygenic risk scores aggregating effects of minor alleles of independent SNPs that were adversely or beneficially associated with disability showed highly significant associations in meta-analysis, p = 3.13 × 10^-45 and p = 5.60 × 10^-23, respectively, and were replicated in each study. The analysis of genetic pathways, related diseases, and biological functions supported the connections of genes for the identified SNPs with disabling and age-related conditions primarily through oxidative/nitrosative stress, inflammatory response, and ciliary signaling. We identified musculoskeletal system development, maintenance, and regeneration as important components of gene functions. The beneficial and adverse gene sets may be differently implicated in the development of musculoskeletal-related disability with the beneficial set characterized, e.g., by regulation of chondrocyte proliferation and bone formation, and the adverse set by inflammation and bone loss.

The Alzheimer's Disease Exposome

INTRODUCTION

Environmental factors are poorly understood in the etiology of Alzheimer's disease (AD) and related dementias. The importance of environmental factors in gene environment interactions (GxE) is suggested by wide individual differences in cognitive loss, even for carriers of AD-risk genetic variants.

RESULTS AND DISCUSSION

We propose the "AD exposome" to comprehensively assess the modifiable environmental factors relevant to genetic underpinnings of cognitive aging and AD. Analysis of endogenous and exogenous environmental factors requires multi-generational consideration of these interactions over age and time (GxExT). New computational approaches to the multi-level complexities may identify accessible interventions for individual brain aging. International collaborations on diverse populations are needed to identify the most relevant exposures over the life course for GxE interactions.

Associations between a laboratory frailty index and adverse health outcomes across age and sex

OBJECTIVE

Early frailty may be captured by a frailty index (FI) based entirely on vital signs and laboratory tests. Our aim was to examine associations between a laboratory-based FI (FI-Lab) and adverse health outcomes, and investigate how this changed with age.

METHODS

Up to 8988 individuals aged 20+ years from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Survey cohorts were included. Characteristics of the FI-Lab were compared to those of a self-reported clinical FI. Associations between each FI and health care use, self-reported health, and disability were examined in the full sample and across age groups.

RESULTS

Laboratory-based FI scores increased with age but did not demonstrate expected sex differences. Women aged 20-39 years had higher FI scores than men; this pattern reversed after age 60 years. FI-Lab scores were associated with poor self-reported health (odds ratio[95% confidence interval]: 1.46[1.39-1.54]), high health care use (1.35[1.29-1.42]), and high disability (1.41[1.32-1.50]), even among those aged 20-39 years.

CONCLUSION

Higher FI-Lab scores were associated with poor health outcomes at all ages. Associations in the youngest group support the notion that deficit accumulation occurs across the lifespan. FI-Lab scores could be utilized as an early screening tool to identify deficit accumulation at the cellular and molecular level before they become clinically visible.

Blood Markers in Healthy-Aged Nonagenarians: A Combination of High Telomere Length and Low Amyloidβ Are Strongly Associated With Healthy Aging in the Oldest Old

Many factors may converge in healthy aging in the oldest old, but their association and predictive power on healthy or functionally impaired aging has yet to be demonstrated. By detecting healthy aging and in turn, poor aging, we could take action to prevent chronic diseases associated with age. We conducted a pilot study comparing results of a set of markers (peripheral blood mononuclear cell or PBMC telomere length, circulating Aβ peptides, anti-Aβ antibodies, and ApoE status) previously associated with poor aging or cognitive deterioration, and their combinations, in a cohort of “neurologically healthy” (both motor and cognitive) nonagenarians (n = 20) and functionally impaired, institutionalized nonagenarians (n = 38) recruited between 2014 and 2015. We recruited 58 nonagenarians (41 women, 70.7%; mean age: 92.37 years in the neurologically healthy group vs. 94.13 years in the functionally impaired group). Healthy nonagenarians had significantly higher mean PBMC telomere lengths (mean = 7, p = 0.001), this being inversely correlated with functional impairment, and lower circulating Aβ40 (total in plasma fraction or TP and free in plasma fraction or FP), Aβ42 (TP and FP) and Aβ17 (FP) levels (FP40 131.35, p = 0.004; TP40 299.10, p = 0.007; FP42 6.29, p = 0.009; TP42 22.53, p = 0.019; FP17 1.32 p = 0.001; TP17 4.47, p = 0.3), after adjusting by age. Although healthy nonagenarians had higher anti-Aβ40 antibody levels (net adsorbed signal or NAS ± SD: 0.211 ± 0.107), the number of participants that pass the threshold (NAS > 3) to be considered as positive did not show such a strong association. There was no association with ApoE status. Additionally, we propose a “Composite Neurologically Healthy Aging Score” combining TP40 and mean PBMC telomere length, the strongest correlation of measured biomarkers with neurologically healthy status in nonagenarians (AUC = 0.904).

The analysis of correlation between frailty index and postoperative complications of aged patients with nodular goiter

OBJECTIVE

To explore the correlation between frailty index (FI) and postoperative complications of aged patients with nodular goiter (NG).

METHODS

A total of 120 aged patients with NG undergoing operative treatment from May 2013 to October 2015 in our hospital were selected. All of them were divided into 3 groups according to the FI as follows: nonfrail group (FI < 0.2), intermediately frail group (0.2 ≤ FI < 0.4), and frail group (FI ≥ 0.4). Clinical data of patients about general data, body mass index, American Society of Anesthesiology (ASA) classification, hospital stays, and postoperative complications were examined. Then, the correlations between the indexes above and FI were examined.

RESULTS

Frailty index and the ASA classification have some relevance (r = .265, P = .007). The postoperative complication rates of total nonfrail group, intermediately frail group, and frail group were, respectively, 4 cases (11.4%), 11 cases (31.4%), and 24 cases (48.0%). With the increase in FI, the incidence of postoperative complications and hospital stays had also significantly increased. The area under receiver operating characteristic curve examining frailty's ability to forecast postoperative complications was 0. 815 (95% CI: 0.675-0.954, P = .000).

CONCLUSION

The level of frailty index is a risk factor for postoperative complications of aged patients with NG. The preoperative frailty index evaluation can provide reference evidence for the treatment of aged NG patients undergoing surgery.

Trajectories of frailty among Chinese older people in Hong Kong between 2001 and 2012: an age-period-cohort analysis

Background

there is little evidence to suggest that older people today are living in better health than their predecessors did at the same age. Only a few studies have evaluated whether there are birth cohort effects on frailty, an indicator of health in older people, encompassing physical, functional and mental health dimensions.

Objectives

this study examined longitudinal trajectories of frailty among Chinese older people in Hong Kong.

Methods

this study utilised data from the 18 Elderly Health Centres of the Department of Health comprising a total of 417,949 observations from 94,550 community-dwelling Chinese people aged ≥65 years in one early birth cohort (1901-23) and four later birth cohorts (1924-29, 1930-35, 1936-41, 1942-47) collected between 2001 and 2012, to examine trajectories of the frailty index and how birth cohorts may have contributed to the trends using an age-period-cohort analysis.

Results

more recent cohorts had higher levels of frailty than did earlier cohorts at the same age, controlling for period, gender, marital status, educational levels, socioeconomic status, lifestyle and social factors. Older age, being female, widowhood, lower education and smoking were associated with higher levels of frailty.

Conclusion

more recent cohorts had higher levels of frailty than did earlier cohorts. Frailty interventions, coupled with early detection, should be developed to combat the increasing rates of frailty in Hong Kong Chinese.

Functional Status of Elderly Nursing Home Residents With Parkinson's Disease

BACKGROUND

Parkinson's disease (PD) is a debilitating neurological disorder that has a significant impact on activities of daily living (ADL). Limited data exists regarding the functional status of nursing home residents with PD.

OBJECTIVE

The study examined the nature, extent, and predictors of limitation of ADL in patients with PD residing in nursing homes.

METHODS

This study used cross-sectional design involving data from the National Nursing Home Survey (NNHS). The dependent variable was the total number of ADL for which the patient needed assistance. Assistance for ADL comprised of five items of transferring, dressing, eating, toileting and bathing. Multivariable linear regression was used to examine the individual, biological and environmental factors associated with assistance needed for ADL.

RESULTS

The nationally representative study sample was of 98,093 nursing home residents with PD for an overall prevalence of 6.57%. The mean age of the study sample was 81.03±0.34 years. Mood symptoms (45%), behavioral symptoms (24%)and dementia (8%) were common among PD patients. Assistance needed for each ADL ranged from 68.24% for eating to 99.25% for bathing. Older age, being married, living in metropolitan statistical area (MSA), living in other place prior to admission, and presence of mood symptoms were positively related to assistance for ADL. Presence of behavioral symptoms and use of levodopa combination therapy were negatively related to assistance for ADL.

CONCLUSIONS

Majority of the nursing home residents with PD had disability in all the five items of ADL. Various individual, environmental and biological factors were associated with ADL in nursing home residents with PD.

A frailty index from common clinical and laboratory tests predicts increased risk of death across the life course

A frailty index (FI) based entirely on common clinical and laboratory tests might offer scientific advantages in understanding ageing and pragmatic advantages in screening. Our main objective was to compare an FI based on common laboratory tests with an FI based on self-reported data; we additionally investigated if the combination of subclinical deficits with clinical ones increased the ability of the FI to predict mortality. In this secondary analysis of the 2003–2004 and 2005–2006 National Health and Nutrition Examination Survey data, 8888 individuals aged 20+ were evaluated. Three FIs were constructed: a 36-item FI using self-reported questionnaire data (FI-Self-report); a 32-item FI using data from laboratory test values plus pulse and blood pressure measures (FI-Lab); and a 68-item FI that combined all items from each index (FI-Combined). The mean FI-Lab score was 0.15 ± 0.09, the FI-Self-report was 0.11 ± 0.11 and FI-Combined was 0.13 ± 0.08. Each index showed some typical FI characteristics (skewed distribution with long right tail, non-linear increase with age). Even so, there were fewer people with low frailty levels and a slower increase with age for the FI-Lab compared to the FI-Self-report. Higher frailty level was associated with higher risk of death, although it was strongest at older ages. Both FI-Lab and FI-Self-report remained significant in a combined model predicting death. The FI-Lab was feasible and valid, demonstrating that even subclinical deficit accumulation increased mortality risk. This suggests that deficit accumulation, from the subcellular to the clinically visible is a useful construct that may advance our understanding of the ageing process.

Adaptation to metabolic dysfunction during aging: Making the best of a bad situation

Mitochondria play a central role in energy metabolism in the process of oxidative phosphorylation. As importantly, they are key in several anabolic processes, including amino acid biosynthesis, nucleotide biosynthesis, heme biosynthesis, and the formation of iron‑sulfur clusters. Mitochondria are also engaged in waste removal in the urea cycle. Their activity can lead to the formation of reactive oxygen species which have damaging effects in the cell. These organelles are dynamic, undergoing cycles of fission and fusion which can be coupled to their removal by mitophagy. In addition to these widely recognized processes, mitochondria communicate with other subcellular compartments. Various components of mitochondrial complexes are encoded by either the nuclear or the mitochondrial genome necessitating coordination between these two organelles. This article reviews another form of communication between the mitochondria and the nucleus, in which the dysfunction of the former triggers changes in the expression of nuclear genes to compensate for it. The most extensively studied of these signaling pathways is the retrograde response whose effectors and downstream targets have been characterized. This response extends yeast replicative lifespan by adapting the organism to the mitochondrial dysfunction. Similar responses have been found in several other organisms, including mammals. Declining health and function during human aging incurs energetic costs. This compensation plays out differently in males and females, and variation in nuclear genes whose products affect mitochondrial function influences the outcome. Thus, the theme of mitochondria-nucleus communication as an adaptive response during aging appears very widespread.

Concordance and Discordance of Self-Rated and Researcher-Measured Successful Aging: Subtypes and Associated Factors

Objectives

To investigate subtypes of successful aging (SA) based on concordance and discordance between self-rated and researcher-defined measures and their associations with demographic, psychosocial, and life satisfaction factors.

Method

We used multinomial logistic regression models to analyze 2013 cross-sectional survey data from 1,962 persons aged 65 and older in Shanghai that measured self-rated successful aging (SSA) with a single global assessment and researcher-defined successful aging (RSA) with a cumulative deficit index reflecting physical, physiological, cognitive, psychological, and social engagement domains. We generated four subtypes based on these two dichotomous variables: nonsuccessful aging (non-SA; meeting neither the criterion of RSA nor the criterion of SSA), RSA-only (meeting the criterion of RSA-only but not the criterion of SSA), SSA-only (meeting the criterion of SSA-only but not the criterion of RSA), and both-successful aging (both-SA; meeting both criteria of RSA and SSA).

Results

In the sample, 32% were nonsuccessful agers, 7% RSA-only, 34% SSA-only, and 27% successful agers. Female gender and older age were associated with lower likelihood of RSA-only and both-SA relative to non-SA, but with greater likelihood of SSA-only. Good socioeconomic conditions and social networks were associated with greater likelihood of SSA-only and both-SA relative to non-SA or RSA-only. Satisfaction with life domains was robustly and positively associated with good successful aging outcomes.

Discussion

Researcher-defined successful aging and self-rated successful aging are different measures with distinct social correlates. Subtypes of concordance and discordance provide a more holistic biopsychosocial conceptualization of successful aging.

Absence of association between frailty index and survival in elderly Brazilians: the FIBRA Study

In Brazil, the frailty index has not been evaluated previously for its capacity to predict mortality in community-dwelling elderly. The objective of the current study was to evaluate the association between frailty index and mortality in the elderly. This was a prospective study consisting of data from the FIBRA Network-2008-2009 in Campinas, São Paulo State, with information on community-dwelling older adults from the urban area and through the Mortality Information System. Comparisons and statistical associations were performed with the following tests: Mann-Whitney, Kruskal-Wallis, chi-square, and Cox regression with 95% confidence intervals. A total of 689 older adults participated 72.1 ± 5.3 years), of whom 68.8% were women. The prevalence rate for frailty was 38.8%, compared to 51.6% for pre-frailty and 9.6% for fit elders; overall mean frailty index was higher in women. There was no association between frailty index and chronological age. Cox regression showed that the variables age HR: 1.10; 95%CI: 1.05-1.15) and gender HR: 0.57; 95%CI: 0.33-0.99) were significantly associated with mortality. No association was found between frailty index and mortality HR: 3.02; 95%CI: 0.24-37.64). Frailty index was not capable of predicting mortality in community-dwelling elderly Brazilians.

Sex differences in frailty: A systematic review and meta-analysis

BACKGROUND

It is a well-described clinical phenomenon that females live longer than males, yet tend to experience greater levels of co-morbidity and disability. Females can therefore be considered both more frail (because they have poorer health status) and less frail (because they have a lower risk of mortality). This systematic review aimed to determine whether this ageing paradox is demonstrated when the Frailty Index (FI) is used to measure frailty.

METHODS

Medline, EMBASE and CINAHL databases were searched for observational studies that measured FI and mortality in community-dwellers over 65years of age. In five-year age groups, meta-analysis determined the sex differences in mean FI (MD=mean FI_female-mean FI_male) and mortality rate.

RESULTS

Of 6482 articles screened, seven articles were included. Meta-analysis of data from five studies (37,426 participants) found that MD values were positive (p<0.001; MD range=0.02-0.06) in all age groups, indicating that females had higher FI scores than males at all ages. This finding was consistent across individual studies. Heterogeneity was high (I²=72.7%), reflecting methodological differences. Meta-analysis of mortality data (13,127 participants) showed that male mortality rates exceeded female mortality rates up until the 90 to 94-years age group. Individual studies reported higher mortality for males at each level of FI, and higher risk of death for males when controlling for age and FI.

CONCLUSIONS

The pattern of sex differences in the FI and mortality of older adults was consistent across populations and confirmed a 'male-female health-survival paradox'.

Socioeconomic status as a moderator between frailty and mortality at old ages

Background

Despite the well-established power of frailty to predict mortality, and the known associations of socioeconomic status (SES) with mortality, it is largely unknown whether the linkage between frailty and mortality varies across different SES groups. This study aims to investigate whether SES moderates the association between frailty and mortality.

Methods

We relied on the 2008/2009 and 2011/2012 waves of the Chinese Longitudinal Healthy Longevity Survey, a nationwide sample of 13,731 adults aged 65 or older in China. Frailty was constructed using a cumulative index of 38 items (with 39 deficits) reflecting different dimensions of health; the index or the proportion of deficits ranges from 0 to 1, with greater scores indicating poorer health condition. SES was measured by a socioeconomic vulnerability index (SEVI) also from a similar cumulative approach consisting of 6 deficits; the proportion of deficits ranges from 0 to 1 with higher scores indicating lower SES. Eight Weibull hazard regression models were performed to examine how SES moderates the linkage between frailty and mortality.

Results

We found that a one percentage point increase in the frailty index was associated with an increased hazard ratio (HR) by 2.7 % (HR = 1.027, 95 % CI: 1.025–1.027); a one percentage point increase in SEVI score was associated with an increased hazard ratio by 0.6 % (HR = 1.006, 95 % CI: 1.004–1.008) controlling for demographics. When interactions between SEVI and frailty index were modeled, the increased mortality risk associated with frailty was weaker among people with lower SES than among people with higher SES (HR = 0.983, 95 % CI: 0.967–0.992). However, the moderating role of SES was diminished when interactions between SES and age and between frailty and age were modeled. With increasing age, the increased mortality risks associated with frailty and socioeconomic vulnerability weakened.

Conclusions

Frailty was a stronger predictor of mortality among individuals with higher SES than those with lower SES. The increased mortality risks associated with socioeconomic vulnerability and frailty weakened with age. Public health programs aimed at improving SES and promoting healthy longevity should start early in old age, or even earlier, and target poor and frail older adults for maximum impact.

Frailty measurement in research and clinical practice: A review

One of the leading causes of morbidity and premature mortality in older people is frailty. Frailty occurs when multiple physiological systems decline, to the extent that an individual's cellular repair mechanisms cannot maintain system homeostasis. This review gives an overview of the definitions and measurement of frailty in research and clinical practice, including: Fried's frailty phenotype; Rockwood and Mitnitski's Frailty Index (FI); the Study of Osteoporotic Fractures (SOF) Index; Edmonton Frailty Scale (EFS); the Fatigue, Resistance, Ambulation, Illness and Loss of weight (FRAIL) Index; Clinical Frailty Scale (CFS); the Multidimensional Prognostic Index (MPI); Tilburg Frailty Indicator (TFI); PRISMA-7; Groningen Frailty Indicator (GFI), Sherbrooke Postal Questionnaire (SPQ); the Gérontopôle Frailty Screening Tool (GFST) and the Kihon Checklist (KCL), among others. We summarise the main strengths and limitations of existing frailty measurements, and examine how well these measurements operationalise frailty according to Clegg's guidelines for frailty classification - that is: their accuracy in identifying frailty; their basis on biological causative theory; and their ability to reliably predict patient outcomes and response to potential therapies.

Dynamical network model for age-related health deficits and mortality

How long people live depends on their health, and how it changes with age. Individual health can be tracked by the accumulation of age-related health deficits. The fraction of age-related deficits is a simple quantitative measure of human aging. This quantitative frailty index (F) is as good as chronological age in predicting mortality. In this paper, we use a dynamical network model of deficits to explore the effects of interactions between deficits, deficit damage and repair processes, and the connection between the F and mortality. With our model, we qualitatively reproduce Gompertz's law of increasing human mortality with age, the broadening of the F distribution with age, the characteristic nonlinear increase of the F with age, and the increased mortality of high-frailty individuals. No explicit time-dependence in damage or repair rates is needed in our model. Instead, implicit time-dependence arises through deficit interactions-so that the average deficit damage rates increase, and deficit repair rates decrease, with age. We use a simple mortality criterion, where mortality occurs when the most connected node is damaged.

Characterizing Frailty Status in the Systolic Blood Pressure Intervention Trial

BACKGROUND

The Systolic Blood Pressure Intervention Trial (SPRINT) is testing whether a lower systolic blood pressure (BP) target of 120 mm Hg leads to a reduction in cardiovascular morbidity and mortality among hypertensive, nondiabetic adults. Because there may be detrimental effects of intensive BP control, particularly in older, frail adults, we sought to characterize frailty within SPRINT to address ongoing questions about the ability of large-scale trials to enroll representative samples of noninstitutionalized, community-dwelling, older adults.

METHODS

We constructed a 36-item frailty index (FI) in 9,306 SPRINT participants, classifying participants as fit (FI ≤ 0.10), less fit (0.10 < FI ≤ 0.21), or frail (FI > 0.21). Recurrent event models were used to evaluate the association of the FI with the incidence of self-reported falls, injurious falls, and all-cause hospitalizations.

RESULTS

The distribution of the FI was comparable with what has been observed in population studies, with 2,570 (27.6%) participants classified as frail. The median FI was 0.18 (interquartile range = 0.14 to 0.24) in participants aged 80 years and older (N = 1,159), similar to the median FI of 0.17 reported for participants in the Hypertension in the Very Elderly Trial. In multivariable analyses, a 1% increase in the FI was associated with increased risk for self-reported falls (hazard ratio [HR] = 1.030), injurious falls (HR = 1.035), and all-cause hospitalizations (HR = 1.038) (all p values < .0001).

CONCLUSIONS

Large clinical trials assessing treatments to reduce cardiovascular disease risk, such as SPRINT, can enroll heterogeneous populations of older adults, including the frail elderly, comparable with general population cohorts.

Frailty still matters to health and survival in centenarians: the case of China

Background

Frailty indicates accumulated vulnerability of adverse health outcomes in later life. Its robustness in predicting dependent living, falls, comorbidity, disability, health change, mortality, and health care utilization at older ages is well-documented. However, almost no studies have ever attempted to examine its robustness in centenarians, mainly due to data unavailability. This study examines prevalence of frailty in centenarians and its predictive powers on subsequent mortality and health conditions.

Methods

We use a sample of 4434 centenarians from the 2002, 2005, 2008, and 2011 waves of the Chinese Longitudinal Healthy Longevity Survey (CLHLS), with elders in three younger age groups 65–79, 80–89, and 90–99 as comparisons. Frailty is measured by a cumulative deficit index (DI) that is constructed from 39 variables covering physical and cognitive function, disease conditions, psychological well-being, and other health dimensions. Survival analysis is conducted to examine how frailty is associated with subsequent mortality at an average follow-up length of 3.7 years (2.6 years for deceased persons died in 2002–2011 and 7.6 years for survived persons at the 2011 wave). Logistic regressions are applied to examine how frailty is associated with subsequent physical and cognitive functions, disease conditions, and self-rated health with an average follow-up length of 3.0 years.

Results

The study reveals that centenarians are frailer than younger elders. The DI scores increase from less than 0.1 at ages 65–79 to over 0.30 in centenarians. Women are frailer than men at all ages. However, there is a great variation in frailty among all age groups. We also find that each additional increase of 0.01 score of the DI is associated with 1.6 % higher mortality risk (95 % CI: 1.014–1.018) in female centenarians and 1.4 % higher mortality risk (95 % CI: 1.010–1.018) in male centenarians, although these associations are weaker than those in other three younger age groups.

Conclusions

Frailty still plays an important role in determining subsequent health outcomes and mortality in centenarians.

Physical, Cognitive, Social, and Emotional Mediators of Activity Involvement and Health in Later Life

The current study tests the indirect effect of activity-related physical activity, cognitive activity, social interaction, and emotional exchange on the relationship between activity involvement and health (physical and emotional) in later life. Longitudinal data from the Health and Retirement Study (N = 5,442) were used to estimate a series of linear regression models. We found significant indirect effects for social interaction and benefit to others (emotional exchange) on emotional health (depressive symptoms) and indirect effects for use of body and benefit to others (physical) on physical health (frailty). The most potent indirect effect associated with emotional and physical health was experienced by those engaged in all four domains (use of body, use of mind, social interaction, and benefit to others). While effect sizes are small and results should be interpreted with caution, findings shed light on ways in which public health interventions aimed toward increasing role engagement in later life could be improved.

Operationalizing Frailty Using the Frailty Phenotype and Deficit Accumulation Approaches

In both demographic and clinical studies, frailty is understood as a multidimensional state of increased vulnerability compared with the status of others of the same age. Of the many theoretical definitions of frailty, two are commonly employed: the physical frailty/phenotypic approach and the deficit accumulation approach. The purpose of this chapter is to discuss how frailty is conceptualized and operationalized based on these two approaches.

Measuring frailty using self-report and test-based health measures

BACKGROUND

previously, frailty indices were constructed using mostly subjective health measures. The reporting error in this type of measure can have implications on the robustness of frailty findings.

OBJECTIVE

to examine whether frailty assessment differs when we construct frailty indices using solely self-reported or test-based health measures.

DESIGN

secondary analysis of data from The Irish LongituDinal study on Ageing (TILDA).

SUBJECTS AND METHODS

4,961 Irish residents (mean age: 61.9 ± 8.4; 54.2% women) over the age of 50 years who underwent a health assessment were included in this analysis. We constructed three frailty indices using 33 self-reported health measures (SRFI), 33 test-based health measures (TBFI) and all 66 measures combined (CFI). The 2-year follow-up outcomes examined were all-cause mortality, disability, hospitalisation and falls.

RESULTS

all three indices had a right-skewed distribution, an upper limit to frailty, a non-linear increase with age, and had a dose-response relationship with adverse outcomes. Levels of frailty were lower when self-reported items were used (SRFI: 0.12 ± 0.09; TBFI: 0.17 ± 0.15; CFI: 0.14 ± 0.13). Men had slightly higher frailty index scores than women when test-based measures were used (men: 0.17 ± 0.09; women: 0.16 ± 0.10). CFI had the strongest prediction for risk of adverse outcomes (ROC: 0.64-0.81), and age was not a significant predictor when it was included in the regression model.

CONCLUSIONS

except for sex differences, characteristics of frailty are similar regardless of whether self-reported or test-based measures are used exclusively to construct a frailty index. Where available, self-reported and test-based measures should be combined when trying to identify levels of frailty.

Biodemographic Analyses of Longitudinal Data on Aging, Health, and Longevity: Recent Advances and Future Perspectives

Biodemography became one of the most innovative and fastest growing areas in demography. This progress is fueled by the growing variability and amount of relevant data available for analyses as well as by methodological developments allowing for addressing new research questions using new approaches that can better utilize the potential of these data. In this review paper, we summarize recent methodological advances in biodemography and their diverse practical applications. Three major topics are covered: (1) computational approaches to reconstruction of age patterns of incidence of geriatric diseases and other characteristics such as recovery rates at the population level using Medicare claims data; (2) methodological advances in genetic and genomic biodemography and applications to research on genetic determinants of longevity and health; and (3) biodemographic models for joint analyses of time-to-event data and longitudinal measurements of biomarkers collected in longitudinal studies on aging. We discuss how such data and methodology can be used in a comprehensive prediction model for joint analyses of incomplete datasets that take into account the wide spectrum of factors affecting health and mortality transitions including genetic factors and hidden mechanisms of aging-related changes in physiological variables in their dynamic connection with health and survival.

Frailty prevalence and 10-year survival in community-dwelling older adults: results from the ESTHER cohort study

The frailty index (FI), defined by a deficit accumulation approach, has emerged as a promising concept in gerontological research, but applications have been mostly restricted to populations from Canada and the United States aged 65 years or older. Baseline data from the German ESTHER cohort study (N 9,886; age 50-75; mean follow-up 8.7 years) were used to create a FI through a deficit accumulation approach. For estimation of frailty prevalence, we used cut-points for the FI to define three categories (non-frail 0 to ≤0.20; pre-frail >0.20 to <0.45; frail ≥0.45). We assessed variation of the FI by age and sex: 10-year survival according to baseline FI was assessed by Kaplan-Meier curves and bivariate and multivariate Cox proportional hazard models. Cubic splines were used to assess sex-specific dose-response associations. Prevalence of frailty was 9.2 and 10.5% in women and men, respectively. Age-specific prevalence of frailty ranged from 4.6% in 50-54 year old participants to 17.0% in 70-75 year old participants. Below 60 years of age, men had a higher FI than women. However, the FI showed a stronger increase with age among women (3.1% per year) than among men (1.7% per year) and was higher among women than men in older age groups. Adjusted hazard ratios (95% confidence intervals) for all-cause mortality were 1.08 (0.84-1.39), 1.32 (1.05-1.66), 1.77 (1.41-2.22), and 2.60 (2.11-3.20) for the 2nd, 3rd, 4th, and 5th quintile of the FI compared to 1st quintile, respectively. There was a strong dose-response relationship between the FI and total mortality among both men and women and both younger (<65 years) and older subjects. We found sex differences in the FI and its increase with age, along with a consistent strong association of the FI with mortality in both sexes, even for age group 50-64.

Frailty index to measure health status in people with systemic sclerosis

OBJECTIVE

To develop and validate, as a measure of overall health status, a Frailty Index (FI) for patients (n=1372) in the Canadian Scleroderma Research Group (CSRG) Registry.

METHODS

Forty-four items were selected from the CSRG database as health deficits and recoded using FI criteria. To test construct validity, we compared measurement properties of the CSRG-FI to other FI, and related it to measures of damage, age, and time since diagnosis. To test criterion validity, we compared the baseline FI to that at last recorded visit and to mortality.

RESULTS

The mean CSRG-FI was 0.33 with a sub-maximal limit of 0.67. In patients with diffuse disease, the mean was 0.38(SD 0.14); in patients with limited disease, the mean was 0.31(SD 0.13). The CSRG-FI was weakly (but significantly) correlated with the Rodnan Skin Score (r=0.28 in people with diffuse disease; 0.18 with limited) and moderately with the Physician Assessment of Damage (r=0.51 for both limited and diffuse). The risk of death increased with higher FI scores and with higher physician ratings of damage. The area under the receiver operating characteristic curve for the baseline FI in relation to death was 0.75, higher than for other measures (range: 0.57-0.67).

CONCLUSION

The FI quantifies overall health status in people with scleroderma and predicts mortality. Whether the FI might help with decisions about who might best be served by more aggressive treatment, such as bone marrow transplantation, needs to be evaluated.

Frailty Index in Europeans: association with determinants of health

AIM

The Frailty Index (FI) summarizes differences in health status within individuals, and the determinants of health drive that variability. The aim of the present study was to investigate the influence of education, income, smoking, alcohol intake and parental longevity on the FI variability in subjects of the same chronological age group.

METHODS

Analyses were based on a 40-item FI based on the first wave of the Survey of Health, Aging and Retirement in Europe (SHARE, http://www.share-project.org/), including 29 905 participants aged ≥50 years from 12 countries. For each sex, the sample was divided into age categories (50s, 60s, 70s, 80s and ≥90), and FI quartiles within age categories were calculated. Multivariate ordinal regressions were computed to assess the relative contribution of the health determinants on the FI quartiles in each age group.

RESULTS

In women, the most significant multivariate predictors were years of education (odds ratios [OR] around 0.9), and difficulties making ends meet (OR between 1.8 and 2.1). In men, the most significant multivariate predictors were years of education (OR around 0.9), difficulties making ends meet (OR between 1.6 and 2.1), mother's age at death (OR under 1), and father's age at death (OR under 1).

CONCLUSIONS

Consistently with the literature, education and income explained, in both sexes, cross-sectional variability in FI in subjects of the same chronological age group. The influence of parental longevity seemed to be greater in men, which mirrors previous studies showing that genetic factors might have a higher impact on longevity in men.

Assessing biological aging: the origin of deficit accumulation

The health of individuals is highly heterogeneous, as is the rate at which they age. To account for such heterogeneity, we have suggested that an individual’s health status can be represented by the number of health deficits (broadly defined by biological and clinical characteristics) that they accumulate. This allows health to be expressed in a single number: the frailty index (FI) is the ratio of the deficits present in a person to the total number of deficits considered (e.g. in a given database or experimental procedure). Changes in the FI characterize the rate of individual aging. The behavior of the FI is highly characteristic: it shows an age specific, nonlinear increase, (similar to Gompertz law), higher values in females, strong associations with adverse outcomes (e.g., mortality), and a universal limit to its increase (at FI ~0.7). These features have been demonstrated in dozens of studies. Even so, little is known about the origin of deficit accumulation. Here, we apply a stochastic dynamics framework to illustrate that the average number of deficits present in an individual is the product of the average intensity of the environmental stresses and the average recovery time. The age-associated increase in recovery time results in the accumulation of deficits. This not only explains why the number of deficits can be used to estimate individual differences in aging rates, but also suggests that targeting the recovery rate (e.g. by preventive or therapeutic interventions) will decrease the number of deficits that individuals accumulate and thereby benefit life expectancy.

New horizons in frailty: ageing and the deficit-scaling problem

All the current frailty measures count deficits. They differ chiefly in which items, and how many, they consider. These differences are related: if a measure considers only a few items, to define broad risks those items need to integrate across several systems (e.g. mobility or function). If many items are included, the cumulative effect of small deficits can be considered. Even so, it is not clear just how small deficits can be. To better understand how the scale of deficit accumulation might impact frailty measurement, we consider how age-related, subcellular deficits might become macroscopically visible and so give rise to frailty. Cellular deficits occur when subcellular damage has neither been repaired nor cleared. With greater cellular deficit accumulation, detection becomes more likely. Deficit detection can be done by either subclinical (e.g. laboratory, imaging, electrodiagnostic) or clinical methods. Not all clinically evident deficits need cross a disease threshold. The extent to which cellular deficit accumulation compromises organ function can reflect not just what is happening in that organ system, but deficit accumulation in other organ systems too. In general, frailty arises in relation to the number of organ systems in which deficits accumulate. This understanding of how subcellular deficits might scale has implications for understanding frailty as a vulnerability state. Considering the cumulative effects of many small deficits appears to allow important aspects of the behaviour of systems close to failure to be observed. It also suggests the potential to detect frailty with less reliance on clinical observation than current methods employ.

Measures of frailty in population-based studies: an overview

Background

Although research productivity in the field of frailty has risen exponentially in recent years, there remains a lack of consensus regarding the measurement of this syndrome. This overview offers three services: first, we provide a comprehensive catalogue of current frailty measures; second, we evaluate their reliability and validity; third, we report on their popularity of use.

Methods

In order to identify relevant publications, we searched MEDLINE (from its inception in 1948 to May 2011); scrutinized the reference sections of the retrieved articles; and consulted our own files. An indicator of the frequency of use of each frailty instrument was based on the number of times it had been utilized by investigators other than the originators.

Results

Of the initially retrieved 2,166 papers, 27 original articles described separate frailty scales. The number (range: 1 to 38) and type of items (range of domains: physical functioning, disability, disease, sensory impairment, cognition, nutrition, mood, and social support) included in the frailty instruments varied widely. Reliability and validity had been examined in only 26% (7/27) of the instruments. The predictive validity of these scales for mortality varied: for instance, hazard ratios/odds ratios (95% confidence interval) for mortality risk for frail relative to non-frail people ranged from 1.21 (0.78; 1.87) to 6.03 (3.00; 12.08) for the Phenotype of Frailty and 1.57 (1.41; 1.74) to 10.53 (7.06; 15.70) for the Frailty Index. Among the 150 papers which we found to have used at least one of the 27 frailty instruments, 69% (n = 104) reported on the Phenotype of Frailty, 12% (n = 18) on the Frailty Index, and 19% (n = 28) on one of the remaining 25 instruments.

Conclusions

Although there are numerous frailty scales currently in use, reliability and validity have rarely been examined. The most evaluated and frequently used measure is the Phenotype of Frailty.

A limit to frailty in very old, community-dwelling people: a secondary analysis of the Chinese longitudinal health and longevity study

BACKGROUND

it has been observed that a frailty index (FI) is limited by the value of 0.7. Whether this holds in countries with higher mortality rates is not known.

OBJECTIVES

to test for and quantify a limit in very old Chinese adults and to relate mortality risk to the FI.

DESIGN

secondary analysis of four waves (1998, 2000, 2002 and 2005) of the Chinese Longitudinal Health and Longevity Study (CLHLS).

SUBJECTS

a total of 6,300 people from 22 of 31 provinces in China, aged 80-99 years at baseline and followed up to 7 years.

METHODS

an FI was calculated as the ratio of actual to 38 possible health deficits. Frequency distributions were used to evaluate the limit to the FI. Logistic regression and survival analysis were used to evaluate the relationship between the FI and mortality.

RESULTS

at each wave, a 99% submaximal limit to frailty was observed at FI = 0.7, despite consecutive losses to death. The death rate for those who were healthiest at baseline (i.e. those in whom the baseline FI = 0) increased from 0.18 at the 2-year follow-up to 0.69 by 7 years. At each wave, 100% mortality at 2 years was observed at FI close to 0.67. A baseline FI >0.45 was associated with 100% 7-year mortality.

CONCLUSIONS

a limit to frailty occurred with FI = 0.7 which was not exceeded at any age or in any wave. There appears to be a demonstrable limit to the number of health problems that people can tolerate.

Frailty and fracture, disability, and falls: a multiple country study from the global longitudinal study of osteoporosis in women

OBJECTIVES

To test whether women aged 55 and older with increasing evidence of a frailty phenotype would have greater risk of fractures, disability, and recurrent falls than women who were not frail, across geographic areas (Australia, Europe, and North America) and age groups.

DESIGN

Multinational, longitudinal, observational cohort study.

SETTING

Global Longitudinal Study of Osteoporosis in Women (GLOW).

PARTICIPANTS

Women (N = 48,636) aged 55 and older enrolled at sites in Australia, Europe, and North America.

MEASUREMENTS

Components of frailty (slowness and weakness, poor endurance and exhaustion, physical activity, and unintentional weight loss) at baseline and report of fracture, disability, and recurrent falls at 1 year of follow-up were investigated. Women also reported health and demographic characteristics at baseline.

RESULTS

Women younger than 75 from the United States were more likely to be prefrail and frail than those from Australia, Canada, and Europe. The distribution of frailty was similar according to region for women aged 75 and older. Odds ratios from multivariable models for frailty versus nonfrailty were 1.23 (95% confidence interval (CI) = 1.07-1.42) for fracture, 2.29 (95% CI = 2.09-2.51) for disability, and 1.68 (95% CI = 1.54-1.83) for recurrent falls. The associations for prefrailty versus nonfrailty were weaker but still indicated statistically significantly greater risk of each outcome. Overall, associations between frailty and each outcome were similar across age and geographic region.

CONCLUSION

Greater evidence of a frailty phenotype is associated with greater risk of fracture, disability, and falls in women aged 55 and older in 10 countries, with similar patterns across age and geographic region.