Sex differences in mortality among older frail Mexican Americans

Sex differences in the frailty phenotype and mortality in the I-Lan longitudinal aging study cohort

BACKGROUND

Frailty is a common geriatric syndrome related to multiple adverse outcomes. Sex differences in its prevalence and impact on mortality remain incompletely understood.

METHODS

This study was conducted with data from the I-Lan Longitudinal Aging Study, in which community-dwelling subjects aged > 50 years without coronary artery disease or diabetes were enrolled. Sex disparities in phenotypically defined frailty and sex-morality predictor interactions were evaluated. Sex- and frailty-stratified analyses of mortality were performed.

RESULTS

The sample comprised 1371 subjects (51.4% women, median age 61 years). The median follow-up period was 6.3 (interquartile range, 5.8-7.0) years. The frailty prevalence did not differ between men (5.3%) and women (5.8%). Frail individuals were older and less educated and had poorer renal function than did non-frail individuals. Body composition trends differed between sexes, regardless of frailty. Relative to non-frail men, frail men had significantly lower body mass indices (BMIs; 24.5 vs. 23.4 kg/m2, p = 0.04) and relative appendicular skeletal muscle masses (7.87 vs. 7.05 kg/m2, p < 0.001). Frail women had significantly higher BMIs (25.2 vs. 23.9 kg/m2, p = 0.02) and waist circumferences (88 vs. 80 cm, p < 0.001) than did non-frail women. Frailty was an independent mortality predictor for men only [hazard ratio (95% confidence interval) = 3.395 (1.809-6.371), psex-frailty interaction = 0.03].

CONCLUSION

Frailty reflected poorer health in men than in women in the present cohort. This study revealed sex disparities in the impact of frailty on mortality among relatively healthy community-dwelling older adults.

Sex differences in frailty manifestations in patients with coronary artery disease

Aim. To analyze the differences in detection rate of prefrailty and frailty syndrome (FS) in male and female patients with multivessel coronary artery disease (CAD) undergoing elective coronary artery bypass grafting (CABG).

Material and methods. The study included 387 patients admitted for elective primary CABG. Screening for prefrailty and FS in patients before surgery was performed using the questionnaire "Age is not a drawback".

Results. In the age group of 45 to 59 years, 25% of females and only 6% of males had signs of FS, while 25% of women and 34% of men did not present with signs of frailty and prefrailty. Half of middle-aged women and 60% of middle-aged men had prefrailty. Between the ages of 60 and 74, only 14% of women and 24% of men were not frail. Elderly women are more likely than elderly men to present with signs of FS (p=0,040). The symptoms of prefrailty in elderly patients were detected at equal rate in men and women (59% and 60%, respectively). All senile-aged patients presented with the signs of prefrailty or FS.

Conclusion. Patients with multivessel CAD present with manifestation of frailty in senile, elderly, and middle age. At the same time, middle-aged and elderly women with the higher rates of comorbid disorders require special attention.

Frailty among older Hispanics living in the United States: A scoping review

A scoping review was conducted to identify the available evidence about frailty among older Hispanics living in the U.S. using the Integral Model of Frailty. A not time-limited search was conducted in five peer-reviewed databases. Identified factors associated with frailty among older Hispanics are presented in four categories: (1) Characteristics and prevalence of frailty, (2) Life course determinants of frailty, (3) Comorbidities associated with frailty, and (4) Adverse outcomes of frailty. A total of 1030 articles were identified, and 37 articles were included in the scoping review. Most studies measured frailty based on the Fried Frailty Phenotype (59.5%, n= 22) and had a longitudinal design (64.9%, n= 24). The overall prevalence of frailty among Hispanics ranged from 4.3% to 37.1% (n= 20 studies). Further research is needed that targets Hispanics from different backgrounds in the U.S., particularly those that are high in number (i.e., Mexicans, Puerto Ricans, and Central Americans).

Cognitive Frailty as a Predictor of Mortality in Older Adults: A Longitudinal Study in Peru

Objective

To evaluate the role of cognitive frailty and its components as risk factors of mortality in older adults of the Centro Médico Naval (CEMENA) in Callao, Peru during 2010-2015.

Methods

We performed a secondary analysis of data from a prospective cohort that included older adults (60 years and older) treated at the CEMENA Geriatrics service between 2010–2015. Frailty was defined as the presence of three or more criteria of the modified Fried Phenotype. Cognitive impairment was assessed using the Peruvian version of the Mini Mental State Examination (MMSE), considering a score <21 as cognitive impairment. Cognitive frailty was defined as the coexistence of both. In addition, we included sociodemographic characteristics, medical and personal history, as well as the functional evaluation of each participant.

Results

We included 1,390 older adults (mean follow-up: 2.2 years), with a mean age of 78.5 ± 8.6 years and 59.6% (n = 828) were male. Cognitive frailty was identified in 11.3% (n = 157) and 9.9% (n = 138) died during follow-up. We found that cognitive frailty in older adults (aHR = 3.57; 95%CI: 2.33–5.49), as well as its components, such as sedentary behavior and cognitive impairment (aHR = 7.05; 95%CI: 4.46–11.13), weakness and cognitive impairment (aHR = 6.99; 95%CI: 4.41–11.06), and exhaustion and cognitive impairment (aHR = 4.51; 95%CI: 3.11–6.54) were associated with a higher risk of mortality.

Conclusion

Cognitive frailty and its components were associated with a higher risk of mortality in older adults. It is necessary to develop longitudinal studies with a longer follow-up and that allow evaluating the effect of interventions in this vulnerable group of patients to limit adverse health outcomes, including increased mortality.

Sex differences in the prevalence and prognostic impact of physical frailty and sarcopenia among older patients with heart failure

BACKGROUND AND AIMS

Frailty and sarcopenia are common and confer poor prognosis in elderly patients with heart failure; however, gender differences in its prevalence or prognostic impact remain unclear.

METHODS AND RESULTS

We included 1332 patients aged ≥65 years, who were hospitalized for heart failure. Frailty and sarcopenia were defined using the Fried phenotype model and Asian Working Group for Sarcopenia criteria, respectively. Gender differences in frailty and sarcopenia, and interactions between sex and prognostic impact of frailty/sarcopenia on 1-year mortality were evaluated. Overall, 53.9% men and 61.0% women and 23.7% men and 14.0% women had frailty and sarcopenia, respectively. Although sarcopenia was more prevalent in men, no gender differences existed in frailty after adjusting for age. On Kaplan-Meier analysis, frailty and sarcopenia were significantly associated with 1-year mortality in both sexes. On Cox proportional hazard analysis, frailty was associated with 1-year mortality only in men, after adjusting for confounding factors (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.19-3.16; P = 0.008 for men; HR, 1.63; 95% CI, 0.84-3.13; P = 0.147 for women); sarcopenia was an independent prognostic factor in both sexes (HR, 1.93; 95% CI, 1.13-3.31; P = 0.017 for men; HR, 3.18; 95% CI, 1.59-5.64; P = 0.001 for women). There were no interactions between sex and prognostic impact of frailty/sarcopenia (P = 0.806 for frailty; P = 0.254 for sarcopenia).

CONCLUSIONS

Frailty and sarcopenia negatively affect older patients with heart failure from both sexes.

CLINICAL TRIALS

This study was registered at the University Hospital Information Network (UMIN-CTR, unique identifier: UMIN000023929) before the first patient was enrolled.

Walking Speed and Mortality: An Updated Systematic Review

OBJECTIVE

The aim of our systematic review was to update the current evidence on the association between slow walking speed (WS) and mortality, expanding the current knowledge available in the literature.

METHODS

A systematic review of the published data on the association of WS and mortality was carried out by searching on PubMed and ISI Web of Knowledge databases.

RESULTS

From a title and abstract analysis, 61 articles were included that met the prespecified criteria. After a full-text analysis, 6 articles were excluded and the remaining articles accounted for 120,838 patients and > 25,148 deaths were registered. The duration of follow-ups ranged between 2 and 21 years. In general, studies have shown a consistent association between WS and mortality from all causes.

CONCLUSIONS

WS showed continuous and consistent evidence to be a good predictor of mortality. As such, our study supports the use of this tool in clinical practice as a way to improve health care.

Frailty in ethnic minority women

In majority populations in high- and middle-income countries, women live longer yet experience higher levels of frailty than men of the same age. It is unclear whether this 'sex-frailty paradox' is present in ethnic minority populations. In this narrative review, we explore biological, behavioural and social factors associated with mortality, morbidity and frailty in women, particularly ethnic minority women. We ascertain that natural menopause occurs earlier in women of particular ethnicities. Ethnic minority women (living in high-income countries) have more children and higher rates of chronic disease and disability, all of which are associated with frailty. In some ethnic minorities, women are less likely to engage in deleterious health behaviours such as smoking and alcohol consumption. However, in others the reverse is true. Women from migrant ethnic minorities tend to have lower levels of physical activity. With time, they can also adopt adverse behavioural patterns of the majority population. Although the evidence is sparse, sex differences in health reporting and social assets, as well as gender roles, are likely to contribute to sex differences in frailty in ethnic minorities. Overall, ethnic minority women are a particularly vulnerable group, but the majority of risk factors for frailty appear to be mutable rather than fixed. Future research may examine interventions that target frailty in different races and ethnicities at individual, population and global levels.

Sex differences in frailty: Comparisons between humans and preclinical models

Frailty can be viewed as a state of physiological decline that increases susceptibility to adverse health outcomes. This loss of physiological reserve means that even small stressors can lead to disability and death in frail individuals. Frailty can be measured with various clinical tools; the two most popular are the frailty index and the frailty phenotype. Clinical studies have used these tools to show that women are frailer than men even though they have longer lifespans. Still, factors responsible for this frailty-mortality paradox are not well understood. This review highlights evidence for male-female differences in frailty from both the clinical literature and in animal models of frailty. We review evidence for higher frailty levels in female animals as seen in many preclinical models. Mechanisms that may contribute to sex differences in frailty are highlighted. In addition, we review work that suggests frailty may play a role in susceptibility to chronic diseases of aging in a sex-specific fashion. Additional mechanistic studies in preclinical models are needed to understand factors involved in male-female differences in frailty in late life.

Low levels of frailty in HIV-positive older adults on antiretroviral therapy in northern Tanzania

There are over 3 million people in sub-Saharan Africa (SSA) aged 50 and over living with HIV. HIV and combined antiretroviral therapy (cART) exposure may accelerate the ageing in this population, and thus increase the prevalence of premature frailty. There is a paucity of data on the prevalence of frailty in an older HIV + population in SSA and screening and diagnostic tools to identify frailty in SSA. Patients aged ≥ 50 were recruited from a free Government HIV clinic in Tanzania. Frailty assessments were completed, using 3 diagnostic and screening tools: the Fried frailty phenotype (FFP), Clinical Frailty Scale (CFS) and Brief Frailty Instrument for Tanzania (B-FIT 2). The 145 patients recruited had a mean CD4 + of 494.84 cells/µL, 99.3% were receiving cART and 72.6% were virally suppressed. The prevalence of frailty by FFP was 2.758%. FFP frailty was significantly associated with female gender (p = 0.006), marital status (p = 0.007) and age (p = 0.038). Weight loss was the most common FFP domain failure. The prevalence of frailty using the B-FIT 2 and the CFS was 0.68%. The B-FIT 2 correlated with BMI (r = − 0.467, p = 0.0001) and CD4 count in females (r = − 0.244, p = 0.02). There is an absence of frailty in this population, as compared to other clinical studies. This may be due to the high standard of HIV care at this Government clinic. Undernutrition may be an important contributor to frailty. It is unclear which tool is most accurate for detecting the prevalence of frailty in this setting as levels of correlation are low.

Frailty as a Predictor of Negative Health Outcomes in Chronic Kidney Disease: A Systematic Review and Meta-Analysis

OBJECTIVES

To perform a comprehensive evidence synthesis to summarize the impact of frailty on health outcomes in patients with chronic kidney disease (CKD).

DESIGN

Systematic reviews and meta-analysis.

SETTING

Electronic searches in PubMed, Embase, Web of Science, CNKI, VIP, CBM, and Wanfang Database were performed. The methodological quality was evaluated using the Newcastle Ottawa Scale (NOS).

PARTICIPANTS

Patients with chronic kidney disease (CKD).

MEASUREMENTS

Potential clinical outcomes due to frailty.

RESULTS

Eighteen cohort studies incorporating a total of 22,788 participants were included. The overall risk of bias was low. The median reported prevalence of frail and prefrail individuals with CKD was 41.8% (range 2.8-81.5%) and 43.9% (range 19.1-62.7%), respectively. Prefrailty and frailty related to mortality indicated an increased hazard ratio (HR), with a pooled HR of 1.68 [95% confidence interval (CI) 1.46-1.94; P < .001] and 1.48 (95% CI 1.21-1.81; P < .001), respectively. Prefrailty and frailty related to hospitalization with the pooled HR/risk ratio (RR) of 1.56 (95% CI 1.37-1.76; P < .001) and 1.21 (95% CI 0.79-1.85; P = .38), respectively. Similarly, the pooled HR demonstrated a strong correlation between frailty and falls in patients with CKD with HR 1.83 (95% CI 1.40-2.37; P < .001) and no statistical correlation between prefrailty and falls in these patients with pooled HR 1.19 (95% CI 0.44-3.22; P = .73), respectively.

CONCLUSIONS AND IMPLICATIONS

Frailty is predictive of negative outcomes in patients with CKD, including all-cause mortality, all-cause hospitalization, and falls. Therefore, frailty should be routinely assessed among patients with CKD to prevent poor prognosis, reduce fatality rate, and provide evidence to support future targeted interventions. However, because of the limited amount of information currently in the literature, additional prospective studies are needed to explore the role of prefrailty in predicting adverse outcomes for patients with CKD.

Does the Impact of Frailty on All-Cause Mortality in Older Persons Differ between Women and Men? A Meta-Analysis

OBJECTIVE

Sex-specific impact of frailty on all-cause mortality in older age population remains controversial. This meta-analysis aimed to evaluate the association between frailty and all-cause mortality in older age women vs men from the general population.

DESIGN

Meta-analysis.

SETTING AND PARTICIPANTS

PubMed and Embase databases were searched until March 25, 2020 for studies reporting sex-specific association of frailty phenotype or index with all-cause mortality among the older general population (age ≥60 years) in the same study.

MEASUREMENTS

All-cause mortality for the frail vs robust individuals.

RESULTS

Eight studies enrolling a total of 87, 000 individuals were identified. Using the frailty phenotype, the pooled risk ratio of all-cause mortality was 2.41 [95% confidence interval (CI) 2.07-2.80] for frail women and 2.94 (95% CI 2.12-4.09) for frail men. Using the frailty index, the pooled risk ratio of all-cause mortality was 3.23 (95% CI 2.16-4.83) for frail women and 2.63 (95% CI 2.33-2.98) for frail men. The pooled female-to-male ratio of relative risks was 0.93 (95% CI 0.76-1.13) for the frailty phenotype and 1.22 (95% CI 0.79-1.88) for the frailty index.

CONCLUSIONS AND IMPLICATIONS

Older men and women with frailty confer a higher risk of all-cause mortality in the general population from the same source. However, there is no significant sex difference in the association between phenotype or index and all-cause mortality.

Combined effects of cognitive impairment and pre-frailty on future frailty and death in older Mexican Americans

Objectives: Impaired cognition and pre-frailty are associated with poor health outcomes. However, research has not examined the combined impact of cognitive impairment and pre-frailty on future frailty and mortality among older Mexican Americans. Methods: Data for this analysis came from the 2006-2007 and 2010-2011 waves of the Hispanic EPESE. The final sample included 639 Mexican Americans aged ≥77 years who were non-frail or pre-frail in 2006-2007. Frailty measure included weight loss, exhaustion, weakness, and slow walking speed. Participants were classified as non-frail (0 criteria) and pre-frail (1 criterion) at baseline. Cognitive impairment was defined as <21 points on the MMSE. At baseline, participants were grouped as: cognitively intact non-frail, cognitively intact pre-frail, cognitively impaired non-frail, and cognitively impaired pre-frail. Logistic and hazard regression models were used to evaluate the odds of being frail in 2010-2011 and risk for 10-year mortality. Results: Cognitively impaired pre-frail participants were more likely to become frail (OR = 4.82, 95% CI = 2.02-11.42) and deceased (HR = 1.99, 95% CI = 1.42-2.78). Cognitively impaired non-frail participants had significantly higher risk for mortality (HR = 1.55, 95% CI = 1.12-2.19) but not frailty (OR = 1.29, 95% CI = 0.50-3.11). Being cognitively intact and pre-frail at baseline was not significantly associated with being frail at follow-up (OR = 1.62, 95% CI = 0.83-3.19) or mortality (HR = 1.29, 95% CI = 0.97-1.71). Conclusions: Comorbid cognitive impairment and pre-frailty is associated with future frailty and mortality in older Mexican Americans. Screening for cognitive impairment may be effective for identifying pre-frail Mexican Americans who are at the highest risk of frailty and mortality.

Older women are frailer, but less often die then men: a prospective study of older hospitalized people

OBJECTIVES

The association between frailty, mortality and sex is complex, but a limited literature is available on this topic, particularly for older hospitalized patients. Therefore, the objective of our study was to prospectively evaluate sex differences in frailty, assessed by the Multidimensional Prognostic Index (MPI) and mortality, institutionalization, and re-hospitalization in an international cohort of older people admitted to hospital.

STUDY DESIGN

We used data from nine public hospitals in Europe and Australia, to evaluate sex differences in mortality, frailty and the risk of institutionalization and re-hospitalization, during one year of follow-up.

MAIN OUTCOME MEASURES

People aged 65 years or more admitted to hospital for an acute medical condition or for a relapse of a chronic disease were included. A standardized comprehensive geriatric assessment, which evaluated functional, nutritional, and cognitive status, risk of pressure sores, comorbidities, medications and co-habitation status, was used to calculate the MPI to measure frailty in all hospitalized older people. Data regarding mortality, institutionalization and re-hospitalization were also recorded for one year.

RESULTS

Altogether, 1140 hospitalized patients (mean age = 84.2 years; 694 women = 60.9%) were included. The one-year mortality rate was 33.2%. In multivariate analysis, adjusted for age, MPI score, centre and diagnosis at baseline, although women had higher MPI scores than men, the latter had higher in-hospital (odds ratio, OR = 2.26; 95% confidence intervals, CI = 1.27-4.01) and one-year post-discharge mortality (OR = 2.04; 95%CI = 1.50-2.79). Furthermore, men were less frequently institutionalized in a care home than female patients (OR = 0.55; 95%CI: 0.34-0.91), but they were also more frequently re-hospitalized (OR = 1.42; 95%CI: 1.06-1.91) during the year after hospital discharge.

CONCLUSION

Older hospitalized men were less frail, but experienced higher in-hospital and one-year mortality than women. Women were admitted more frequently to nursing homes and experienced a lower risk of re-hospitalization. These findings suggest important differences between the sexes and extends the 'male-female health-survival paradox' to acutely ill patient groups.

Frailty Status Predicts All-Cause and Cause-Specific Mortality in Community Dwelling Older Adults

OBJECTIVES

To examine the relationship between frailty status and risk of all-cause and cause-specific mortality.

DESIGN

Longitudinal cohort study with an 11-year follow up.

SETTING AND PARTICIPANTS

Data from the Survey on Health, Aging and Retirement in Europe (SHARE) were used. In the analysis, we included data from 11 European countries. We included men and women older than 50 years residing in Europe. Overall, 24,634 participants were analyzed with a mean age of 64.2 (9.8), 53.6% female, where 14.7% and 6.9% were found to be prefrail or frail, respectively, at the baseline.

METHODS

Frailty status was calculated using the SHARE-Frailty Instrument, categorizing the participants as robust, prefrail, and frail. Multivariate Cox regression models were used to estimate the risk of all-cause and cause-specific (stroke, heart attack, other cardiovascular disease, cancer, respiratory illness, infectious, and digestive and other) mortality.

RESULTS

During the follow-up, and after adjusting for sex, age, education, body mass index, smoking, alcohol consumption, and number of comorbidities, frailty was associated with a higher risk of all-cause (HR 2.17, 95% CI 1.90-2.48) and mortality due to stroke (HR 2.06, 95% CI 1.37-3.10), heart attack (HR 1.67, 95% CI 1.19-2.34), other cardiovascular disease (HR 2.77, 95% CI 1.87-4.12), cancer (HR 2.11, 95% CI 1.63-2.73), respiratory disease (HR 2.76, 95% CI 1.66-4.60), infectious diseases (HR 1.79, 95% CI 1.03-3.11), and digestive and other causes (HR 2.02, 95% CI 1.51-2.71). Prefrailty was associated with a higher risk of all-cause (HR 1.47, 95% CI 1.31-1.63), heart attack (HR 1.31, 95% CI 1.01-1.72), other cardiovascular disease (HR 2.03, 95% CI 1.46-2.81), respiratory disease (HR 1.70, 95% CI 1.09-2.65), and digestive and other causes (HR 1.50, 95% CI 1.18-1.91) mortality.

CONCLUSIONS AND IMPLICATIONS

Baseline prefrailty and frailty are associated with increased all-cause and cause-specific mortality over an 11-year follow up. Public health policy should include preventive programs aimed at older adults to prevent frailty and reduce mortality.

Muscle Strength and Functional Limitations: Preserving Function in Older Mexican Americans

OBJECTIVES

Understanding the role of muscle strength as a preventive factor for shorter-term declines in function may provide further insights into the disabling process. This study examined if muscle strength was associated with 2-year preservation of instrumental activities of daily living (IADL) function and activities of daily living (ADL) disability status in older Mexican Americans.

DESIGN

Longitudinal, panel.

SETTING

Urban and rural households in the Southwestern United States.

PARTICIPANTS

A subsample of 672 Mexican Americans aged at least 65 years was followed for 2 years.

MEASUREMENTS

Muscle strength was assessed with a hand-held dynamometer. IADL and ADL were self-reported. Covariate-adjusted ordinal and multinomial logistic models were used to determine the association between handgrip strength and changes in IADL function, and ADL disability status over 2 years.

RESULTS

Every 10-kg increase in handgrip strength was associated with 5% decreased odds [odds ratio (OR): 0.95; 95% confidence interval (CI): 0.92, 0.98] of experiencing a lost IADL function in 2 years. Likewise, every 10-kg increase in handgrip strength was associated with an 8% decreased odds (OR: 0.92; CI: 0.88, 0.97) for 2-year onset ADL disability, 12% decreased odds (OR: 0.88; CI: 0.83, 0.94) for 2-year ADL disability progression, and 7% decreased odds (OR: 0.93; CI: 0.89, 0.98) for 2-year ADL disability improvement, compared to those with no ADL disability at baseline and follow-up.

CONCLUSIONS

Higher muscle strength was related to a lower risk for 2-year onset of IADL and ADL disability in older Mexican Americans. Future investigations are warranted to examine how potential mediators influence the association between muscle strength and function, to inform interventions aiming to retain function in vulnerable older adult populations.

Risk of death in elderly persons based on the frailty phenotype and the frailty index: a review study

Abstract Objective: to systematize studies evaluating the relationship between frailty and mortality in community-dwelling elderly persons. Method: Frailty was defined according to the frailty phenotype proposed by Fried et al. and the frailty index described by Rockwood et al. The study included epidemiologic population-based studies, cohort surveys, systematic reviews and meta-analyses published in English between 2006 and March 2016 based on the use of the terms: "frail elderly" and "mortality". Only study samples that exclusively comprised adults 65 years old or older who lived in the community were included. Studies investigating hospitalized and institutionalized elderly persons, and those examining the relationship between frailty and mortality through a disease-specific target were excluded. Results: a total of 244 studies were identified, of which 17 met the inclusion criteria. Thirteen studies used the frailty phenotype and four studies used the frailty index. Conclusion: both assessment measures found that frail elderly persons have a higher risk of death than robust elderly persons.

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'.

[Frailty and long term mortality, disability and hospitalisation in Spanish older adults. The FRADEA Study]

INTRODUCTION

The objective of this study was to analyse whether frailty is related to long-term mortality, incident disability in basic activities of daily living (BADL), and hospitalisation.

MATERIAL AND METHODS

A concurrent cohort study conducted on 993 participants over age 70 from the FRADEA Study. Frailty was determined with Fried frailty phenotype. Data was collected on mortality, hospitalisation and incident disability in BADL (bathing, grooming, dressing, toileting, eating or transferring) during the follow-up period. The risk of adverse events was determined by logistic regression, Kaplan-Meier analysis, and Cox proportional hazard analysis adjusted for age, sex, Barthel index, comorbidity and institutionalization.

RESULTS

Mean follow-up was 952 days (SD 408), during which 182 participants (18.4%) died. Frail participants had an increased adjusted risk of death (HR 4.5, 95%CI: 1.8-11.1), incident disability in BADL (OR 2.7, 95%CI: 1.3-5.9) and the combined event mortality or incident disability (OR 3.0, 95%CI: 1.5-6.1). Pre-frail subjects had an increased adjusted risk of death (HR 2.9, 95%CI: 1.2-6.5), incident disability in BADL (OR 2.1, 95%CI: 1.2-3.6), and the combined event mortality or incident disability (OR 2.2, 95%CI: 1.3-3.6). There was a positive association between frailty and hospitalisation, which almost reached statistical significance (OR 1.7, 95%CI: 1.0-3.0).

CONCLUSIONS

Frailty is long-term associated with mortality and incident disability in BADL in a Spanish cohort of older adults.

Frailty and Mortality Outcomes in Cognitively Normal Older People: Sex Differences in a Population-Based Study

OBJECTIVES

To characterize frailty in cognitively normal older adults at baseline and to investigate the relationship between frailty and mortality.

DESIGN

Population-based prospective cohort study: Mayo Clinic Study of Aging.

SETTING

Olmsted County, Minnesota.

PARTICIPANTS

Cognitively normal older persons aged 70 and older (mean age 78.8±5.2, 50.2% male; N=2,356).

MEASUREMENTS

Frailty was assessed at baseline using a 36-item Frailty Index. Four frailty subgroups were identified based on the Frailty Index (≤0.10 (fit), 0.11-0.20 (at risk), 0.21-0.30 (frail), >0.30 (frailest)). All participants underwent comprehensive clinical and cognitive assessments. The association between frailty and mortality was assessed using Cox proportional hazards models.

RESULTS

The median Frailty Index was 0.17 (interquartile range 0.11-0.22). Frailty increased with age and was more common in older men than in older women. Over a median follow-up of 6.5 years (range 7 days to 8.9 years), 500 of the 2,356 participants died, including 292 men. The frailest participants had the greatest risk of death (hazard ratio (HR)=3.91, 95% confidence interval (CI)=2.69-5.68). The association was stronger in women (HR=5.26, 95% CI=2.88-9.61) than men (HR=3.15, 95% CI=1.98-5.02).

CONCLUSION

Baseline frailty was common, especially in older men, and increased with age. Frailty was associated with significantly greater risk of death, particularly in women. These sex differences should be considered when designing a geriatric care plan.

Sex and ethnic-origin specific BMI cut points improve prediction of 40-year mortality: the Israel GOH study

BACKGROUND

Although obesity has been associated with a higher risk for premature death, the sex and ethnic-origin specific body mass index (BMI) levels that are associated with increased mortality are controversial. We investigated the 40-year cumulative all-cause mortality, in relation to the BMI in adult life, among men and women originating from Yemen, Europe/America, Middle East and North Africa, using sex and ethnic-origin specific BMI cut points.

METHODS

A random stratified cohort (n = 5710) was sampled from the central population registry and followed since 1969 for vital status. Weight, height and blood pressure were measured, and smoking status was recorded at baseline. BMI was analysed according to conventional categories and according to sex and ethnic-origin specific quintiles.

RESULTS

Elevated and significant mortality hazard ratios (HRs) of 1.21 [95% confidence interval (CI) 1.00-1.45] for women and 1.22 (95%CI 1.03-1.44) for men were found for the highest origin-specific BMI quintile. In men, the lowest ethnic-origin specific quintile was also significantly associated with increased mortality (HR of 1.22 95% CI 1.03-1.45), adjusting for age, smoking and blood pressure. Obesity was associated with mortality in non-smokers (HR = 1.29, 95% CI 1.04-1.61 in men and HR = 1.46, 95% CI 1.19-1.79 in women), whereas leanness was associated with mortality only among smoking men (HR = 1.39, 95% CI 1.09-1.77).

CONCLUSION

Refinement of BMI categories using country of origin specific quintiles demonstrated significantly increased mortality in the upper quintile in both sexes, while according to the conventional values this association did not prevail in men. We propose the establishment of sex and origin-specific BMI categories when setting goals for disease prevention.

Frail phenotype and mortality prediction: a systematic review and meta-analysis of prospective cohort studies

AIM

This study focused on older adults living in communities, primarily to investigate the relationship between physical frailty and mortality, and secondly to examine gender and age effects on the relationship between frailty and mortality.

BACKGROUND

The World Health Organization indicated that frailty has become an indicator of a lack of successful aging. Systematic literature reviews have yet to focus on the association between various frailty phases and mortality. Meanwhile, few studies researched gender and age effects on the correlation between physical frailty and mortality among older adults living in communities.

DESIGN

A systematic review and meta-analysis of prospective studies.

METHOD

Frailty was assessed according to the Cardiovascular Health Study by Fried et al., who defined a frail phenotype as exhibiting the following five properties: weight loss, exhaustion, weakness, low physical activity, and mobility impairment. We included original epidemiologic population-based studies, cohort surveys, systematic reviews, and meta-analyses. Study samples included only adults aged 65 years or older who lived in communities. We excluded studies investigating hospitalised, institutionalised older adults, and those that examined disease-specific targets. We performed a pooled analysis of mortality of frailty by employing a random-effects model.

RESULTS

A total of 35,538 older adults and 7994 deaths were included in the meta-analysis. We identified 11 population-based studies that examined the relationship between mortality and frailty status in older adults. Compared with robust older adults, older people with frailty have the highest risks of mortality, followed by older people in the pre-frail phase. Older men with frailty have a higher risk of mortality than do frail older women. No age threshold for mortality risk was observed.

CONCLUSION

Frailty is a prevalent and critical geriatric syndrome associated with decreased survival. Through geriatric assessment of frailty, essential information pertaining to mortality among older adults can be obtained.

Identifying common characteristics of frailty across seven scales

OBJECTIVES

To determine whether commonly used frailty scales exhibit shared characteristics when applied to a representative sample of middle-aged and older Europeans.

DESIGN

Secondary analysis of the Survey of Health, Ageing, and Retirement in Europe (SHARE).

SETTING

Eleven European countries.

PARTICIPANTS

Community-dwelling adults (N = 27,527; mean age 65.3 ± 10.5, 55% female).

MEASUREMENTS

Frailty was assessed using SHARE-operationalized versions of seven frailty scales: Edmonton Frail Scale, FRAIL scale, Groningen Frailty Indicator, frailty phenotype, Tilburg Frailty Indicator, a 70-item frailty index (FI), and a 44-item frailty index based on Comprehensive Geriatric Assessment.

RESULTS

All frailty scales demonstrated right-skewed density distributions. On all scales, frailty scores increased nonlinearly with age, between 1% (FRAIL) and 3.6% (FI) per year on a log scale. Frailty scores on all scales exhibited dose-response relationships with 5-year mortality. On all scales, women had higher frailty scores than men of the same age but demonstrated better survival than did men with the same frailty score. On all scales except the frailty phenotype, 99% of participants had scores below the scale's theoretical maximum.

CONCLUSION

On each frailty scale, frailty score increased nonlinearly with age, mortality risk increased with frailty score, and women had higher scores than men but demonstrated better survival. Each scale except the frailty phenotype demonstrated an upper limit to frailty below the scale's theoretical maximum. Across commonly used frailty scales, these characteristics are common in nature but differ in magnitude.

Prevalência e fatores associados à fragilidade em idosos institucionalizados das regiões Sudeste e Centro-Oeste do Brasil

OBJETIVOS: Estimar a prevalência de fragilidade e identificar os fatores associados à fragilidade em indivíduos residentes em instituições de longa permanência para idosos das regiões Centro-Oeste e Sudeste do Brasil. MÉTODOS: Estudo seccional, com 442 idosos institucionalizados de quatro municípios brasileiros. A fragilidade foi avaliada pela versão brasileira do Tilburg Frailty Indicator (TFI). Foram descritas as características da população e estimada a prevalência da fragilidade. Efetuou-se a descrição dos escores total e dos domínios do instrumento. Utilizou-se a regressão de Poisson para explorar as associações observadas, após ajuste para confundimento. RESULTADOS: Grande parte da população era masculina (64,3%), escolarizada (74,1%) e a média de idade era de 75,0 (9,9) anos. A prevalência de fragilidade foi de 52,0%. A média do escore total do TFI foi de 4,9 (2,5) pontos e as médias dos escores dos domínios físico, social e psicológico corresponderam a 2,8 (1,7), 1,3 (0,9) e 0,8 (0,8), respectivamente. Mostraram-se associadas à fragilidade em idosos institucionalizados: idade elevada, analfabetismo, comorbidades e polifarmácia. No modelo multivariado, somente analfabetismo e comorbidades mantiveram sua significância estatística (RP=1,28 IC95% 1,07-1,54 e RP=1,48 IC95% 1,21-1,81). CONCLUSÕES: A prevalência de fragilidade foi maior do que a observada nos outros dois estudos que avaliaram idosos institucionalizados. As associações identificadas são corroboradas pela literatura científica. O TFI é um instrumento multidimensional baseado em um conceito integral da fragilidade e a versão brasileira se mostrou adequada para avaliar esta condição em idosos institucionalizados. Entretanto, é importante realizar estudos que avaliem sua utilização em idosos residentes na comunidade.

[Frailty as a predictor of adverse events in epidemiological studies: literature review]

Several epidemiological studies have analyzed the association between frailty status and adverse geriatric health outcomes, with there being a clear relationship being demonstrated in mortality, disability, mobility loss, institutionalization and falls. However, different studies have evaluated different number of these adverse events, with different criteria, and with different follow-up periods. As a result of this relationship, the objective of geriatric medicine must not only be the prevention, diagnosis and treatment of diseases based on multidisciplinary team work and use of geriatric units according to functional status of patients, but the detection, prevention and treatment of frailty. Frailty must be considered as a pre-disability state that can be prevented and treated to delay its progression towards disability, institutionalization, and death. The characterization of frailty status can also help other medical specialties to stratify the risk of adverse health outcomes in oncology treatments, surgical interventions, or diagnostic procedures.

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.

Activities of daily living dependency and disease-specific mortality during 12-year follow-up in an 80-year-old population

BACKGROUND AND AIMS

Although total mortality is likely to be higher in elderly individuals with frailty or impaired activities of daily living (ADL), little is known about the relationships between disease-specific mortality and ADL dependency in the elderly. Therefore, we examined whether 12-year disease-specific mortality may be associated with ADL dependency in an 80-year-old population.

METHODS

In 1998, of 1,282 community-dwelling residents of Japan's Fukuoka Prefecture, 824 (64.3 %) (309 males and 515 females) participated, the remaining 458 subjects did not participate, and their deaths and causes of death were followed up for 12 years after the baseline examination. ADL dependency was determined according to the guidelines for disabled elderly from the Health, Labor, and Welfare Ministry of Japan, and ADL dependency was measured only at baseline.

RESULTS

During the 12-year follow-up, 506 died, 276 did not die, and 42 were lost. Of the 506 who died, 128 died due to cardiovascular disease, 96 to respiratory tract disease, 87 to cancer, and 51 to senility. The subjects were classified into three groups as follows: ADL-1 (independent group, n = 600), ADL-2 (almost-independent group, n = 113), and ADL-3 (dependent group, n = 93).Total-cause mortality was 2.8 times higher in ADL-3 subjects, respiratory disease mortality was 4.1 times higher in ADL-3 subjects, and senility mortality was 5.7 times higher in ADL-3 subjects than in ADL-1 subjects, after adjusting for various confounding factors. There was no association between mortality due to cancer or cardiovascular disease and ADL dependency.

CONCLUSIONS

We found an independent association between ADL dependency and mortality due to all causes, respiratory disease or senility, but no association with mortality due to cancer or cardiovascular disease. These findings suggest that improving ADL dependency may reduce all mortality and mortality due to respiratory disease or senility.

Psychometric properties of the Brazilian version of the Tilburg frailty indicator (TFI)

This study aims to assess the psychometric properties of the Brazilian version of the TFI, an instrument that identifies frailty in elderly individuals. We interviewed 219 individuals aged 60 or older, living in the community. Individuals were predominantly female (52.5%) and mean age was 70.5 (±7.9) years. In order to assess test-retest reliability, 101 individuals were re-interviewed by the same observer within seven to ten days after the first interview. The internal consistency of the instrument was assessed using Cronbach's alpha. To assess construct validity, we used established alternative measures for the items that constitute the TFI, such as: body mass index (BMI), timed up and go (TUG) test, whisper test, Snellen test, upper extremity strength clinical test and mini-mental state examination (MMSE). The test-retest reliability showed high percent agreement for all the items of the instrument, with values ranging from 63% to 100%. Test-retest reliabilities were good (total TFI score r=0.88; physical domain r=0.88; psychological domain r=0.88; and social domain r=0.67). Internal consistency reliability of the Brazilian version was satisfactory (Cronbach's alpha=0.78). The correlations between TFI items and their corresponding measures were consistent except for one item (related to "ability to deal with problems"), demonstrating both convergent and divergent construct validity of the TFI and its items. After the completion of all stages of transcultural adaptation, the Brazilian version of the TFI proved to be well suited for assessing frailty in the elderly population of Brazil.

The frailty index in Europeans: association with age and mortality

BACKGROUND

the frailty index (FI) is an approach to the operationalisation of frailty based on accumulation of deficits. It has been less studied in Europeans.

OBJECTIVE

to construct sex-specific FIs from a large sample of Europeans and study their associations with age and mortality.

DESIGN

longitudinal population-based survey.

SETTING

the Survey of Health, Ageing and Retirement in Europe (SHARE, http://share-dev.mpisoc.mpg.de/).

SUBJECTS

a total of 16,217 females and 13,688 males aged ≥50 from wave 1 (2004-05). Mortality data were collected between 2005 and 2006 (mean follow-up: 2.4 years).

METHODS

regression curve estimations between age and an FI constructed as per the standard procedure. Logistic regressions were used to assess the relative effects of age and the FI towards mortality.

RESULTS

in both sexes, there was a significant non-linear association between age and the FI (females: quadratic R(2) = 0.20, P < 0.001; males: quadratic R(2) = 0.14, P < 0.001). Overall, the FI was a much stronger predictor of mortality than age, even after adjusting for the latter (females: age-adjusted OR 100.5, 95% confidence interval (CI): 46.3-218.2, P < 0.001; males: age-adjusted OR 221.1, 95% CI: 106.7-458.4, P < 0.001).

CONCLUSION

the FI had the expected properties in this large sample of Europeans.

One-year follow-up of non-institutionalized dependent older adults: mortality, hospitalization, and mobility

Non-institutionalized dependent older adults present high morbidity and mortality, demand care from their families, and consume primary health care resources. To expand knowledge about this group, we conducted a population-based one-year prospective cohort study of 130 non-institutionalized dependent older persons (age 60 and older), stratified according to baseline mobility: independent walking (group A), use of walking aids (group B), and bedridden or confined to a wheelchair (group C). The outcomes analysed were death, hospitalization, and mobility disability. Total mortality was 8.5 per cent (p = .05). Overall hospitalization rate was 34.6 per cent; the main causes were stroke and pneumonia. After one year, there was a decline in the proportion of subjects classified as independent walking (57% vs. 43%; p = .03). We conclude that there was a high rate of mortality and hospitalization in this group of dependent older people, and an increase in disability after a one-year follow-up.

The frailty syndrome: a comprehensive review

The frailty syndrome is defined as unintentional weight and muscle loss, exhaustion, and declines in grip strength, gait speed, and activity. Evidence with respect to the clinical definition, epidemiology, mechanisms, interactions, assessment, prevention, and treatment of frailty in the older adult is reviewed.

The protective effect of neighborhood composition on increasing frailty among older Mexican Americans: a barrio advantage?

OBJECTIVE

Little is known about the nature of the frailty syndrome in older Hispanics who are projected to be the largest minority older population by 2050. The authors examine prospectively the relationship between medical, psychosocial, and neighborhood factors and increasing frailty in a community-dwelling sample of Mexican Americans older than 75 years.

METHOD

Based on a modified version of the Cardiovascular Health Study Frailty Index, the authors examine 2-year follow-up data from the Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE) to ascertain the rates and determinants of increasing frailty among 2,069 Mexican American adults 75+ years of age at baseline.

RESULTS

Respondents at risk of increasing frailty live in a less ethnically dense Mexican-American neighborhood, are older, do not have private insurance or Medicare, have higher levels of medical conditions, have lower levels of cognitive functioning, and report less positive affect.

DISCUSSION

Personal as well as neighborhood characteristics confer protective effects on individual health in this representative, well-characterized sample of older Mexican Americans. Potential mechanisms that may be implicated in the protective effect of ethnically homogenous communities are discussed.

[The Frailty Instrument for primary care of the Survey of Health, Ageing and Retirement in Europe (SHARE-FI): results of the Spanish sample]

BACKGROUND

Frailty is a syndrome with important epidemiological and clinical implications in older adults. One of the most accepted definitions of frailty is that of Fried and Walston, who operationalised it according to five well defined criteria. However, their criteria are not readily applicable in primary care, where practitioners need tools to identify patients who require priority access to more specialised resources. With that objective in mind, our research group published the Frailty Instrument of the Survey of Health, Ageing and Retirement in Europe (SHARE-FI). The present paper reports the results of the Spanish sample.

METHODS

In the wave 1 of SHARE (2004), the Spanish sample was composed of 1,279 women and 933 men, all living in the community (mean age: 65.6 years). For each sex, a latent class analysis was used to summarise the five (adapted) frailty criteria into three incremental frailty classes. We tested the association of the frailty classes against a biopsychosocial range of wave 1 variables; the predictive validity of the frailty classes was tested using mortality data from the second wave of SHARE (2006-2007), which were available for 846 women and 660 men.

RESULTS

The frailty classes had the expected cross-sectional associations. The age-adjusted Odds ratio for mortality (with 95% confidence interval) associated with the frail class was 3.2 (1.0-10.2) for women and 8.3 (3.1-22.1) for men.

DISCUSSION

SHARE-FI is a valid and freely accessible instrument, which is intended to facilitate the adoption of the frailty paradigm in primary care.