Frailty Phenotype and Cause-Specific Mortality in the United States

Joint trajectories of pain, depression and frailty and associations with adverse outcomes among community-dwelling older adults: A longitudinal study

This study aimed to examine joint trajectories of pain, depression and frailty and their associations with adverse outcomes. Four waves of national data from the China Health and Retirement Longitudinal Study (CHARLS 2011-2018) were used, involving 4217 participants aged ≥60 years. Joint trajectories were fit using parallel-process latent class growth analysis, and their associations with adverse outcomes were evaluated using modified Poisson regression. Four joint trajectories were identified. Compared with most favorable group, other three joint trajectory groups had higher risk of functional disability and hospitalization. Slowly progressive pain, depression and frailty and persistent combination of pain, depression and frailty were also associated with cognitive decline, while slowly reduced pain and depression but persistent frailty was associated with all-cause mortality. The findings highlight unique characteristics and health impacts of concurrent changes in pain, depression and frailty over time, implicating the integrated physical and psychological care for older adults.

A pilot study to identify factors associated with frailty within the World Trade Center general responder cohort

BACKGROUND

Given the significant exposures experienced by the World Trade Center (WTC) general responders, there is increasing interest in understanding the effect of these exposures on aging in this population. We aim to identify factors that may be associated with frailty, a clinical syndrome characterized by a decrease in one's reserve that has been linked to poor health outcomes.

METHODS

WTC general responders enrolled in the WTC Health Program aged 50 and older provided informed consent. Validated frailty assessments, the Frailty Phenotype (with the Johns Hopkins Frailty Assessment Calculator) along with the FRAIL scale, categorized nonfrail from prefrail/frail. Fall risk, functional status, and cognition were also assessed. WTC variables, including an identified WTC-certified condition, were utilized. The risk of frailty was estimated using log binomial regression analysis. A 95% confidence interval (CI) was used to estimate the prevalence ratio (PR).

RESULTS

One hundred and six participants were included; 38 (35.8%) were classified as pre-frail or frail. More of the pre-frail/frail group were obese (57.9% vs. 25%; p = 0.004) and had a WTC-certified condition (78.9% vs. 58.8%; p = 0.036). Obesity (PR = 2.43, 95% CI = 1.31, 4.53), a WTC-certified condition (PR = 1.77, 95% CI = 1.09, 2.89), and risk of falling (PR = 1.97, 95% CI = 1.01, 3.84) were independently associated with frailty.

CONCLUSIONS

Obesity and having a WTC-certified condition were found to be risk factors for frailty in our pilot study. Future work may focus on further identifying risk factors for frailty in the larger WTC general responder population.

Trajectories of medical care expenditure in the last year of life associated with long-term care utilization in frail older adults: A retrospective cohort study

BACKGROUND

Medical care and long-term care utilization in the last year of life of frail older adults could be a key indicator of their quality of life. This study aimed to identify the medical care expenditure (MCE) trajectories in the last year of life of frail older adults by investigating the association between MCE and long-term care utilization in each trajectory.

METHODS

The retrospective cohort study of three municipalities in Japan included 405 decedents (median age at death, 85 years; 189 women [46.7%]) from a cohort of 1,658 frail older adults aged ≥65 years who were newly certified as support level in the long-term care insurance program from April 2012 to March 2013. This study used long-term care and medical insurance claim data from April 2012 to March 2017. The primary outcome was MCE over the 12 months preceding death. Group-based trajectory modeling was conducted to identify the MCE trajectories. A mixed-effect model was employed to examine the association between long-term care utilization and MCE in each trajectory.

RESULTS

Participants were stratified into four groups based on MCE trajectories over the 12 months preceding death as follows: rising (n = 159, 39.3%), persistently high (n = 143, 35.3%), minimal (n = 56, 13.8%), and descending (n = 47, 11.6%) groups. Home-based long-term care utilization was associated with increased MCE in the descending trajectory (coefficient, 1.48; 95% confidence interval [CI], 1.35-1.62). Facility-based long-term care utilization was associated with reduced MCE in the rising trajectory (coefficient, 0.59; 95% CI, 0.50-0.69). Both home-based (coefficient, 0.92; 95% CI, 0.85-0.99) and facility-based (coefficient; 0.53; 95% CI, 0.41-0.63) long-term care utilization were associated with reduced MCE in the persistently high trajectory.

CONCLUSIONS

These findings may facilitate the integration of medical and long-term care models at the end of life in frail older adults.

Frailty, but not cognitive impairment, improves mortality risk prediction among those with chronic kidney disease-a nationally representative study

BACKGROUND

Though older adults with chronic kidney disease (CKD) have a greater mortality risk than those without CKD, traditional risk factors poorly predict mortality in this population. Therefore, we tested our hypothesis that two common geriatric risk factors, frailty and cognitive impairment, and their co-occurrence, might improve mortality risk prediction in CKD.

METHODS

Among participants aged ≥ 60 years from National Health and Nutrition Examination Survey (2011-2014), we quantified associations between frailty (physical frailty phenotype) and global/domain-specific cognitive function (immediate-recall [CERAD-WL], delayed-recall [CERAD-DL], verbal fluency [AF], executive function/processing speed [DSST], and global [standardized-average of 4 domain-specific tests]) using linear regression, and tested whether associations differed by CKD using a Wald test. We then tested whether frailty, global cognitive impairment (1.5SD below the mean), or their combination improved prediction of mortality (Cox models, c-statistics) compared to base models (likelihood-ratios) among those with and without CKD.

RESULTS

Among 3,211 participants, 1.4% were cognitively impaired, and 10.0% were frail; frailty and cognitive impairment co-occurrence was greater among those with CKD versus those without (1.2%vs.0.1%). Frailty was associated with worse global cognitive function (Cohen's d = -0.26SD,95%CI -0.36,-0.17), and worse cognitive function across all domains; these associations did not differ by CKD (pinteractions > 0.05). Mortality risk prediction improved only among those with CKD when accounting for frailty (p[likelihood ratio test] < 0.001) but not cognitive impairment.

CONCLUSIONS

Frailty is associated with worse cognitive function regardless of CKD status. While CKD and frailty improved mortality prediction, cognitive impairment did not. Risk prediction tools should incorporate frailty to improve mortality prediction among those with CKD.

Differential sensitivity of intraindividual variability dispersion and global cognition in the prediction of functional outcomes and mortality in precariously housed and homeless adults

OBJECTIVE

To examine cognitive intraindividual variability (IIV) dispersion as a predictor of everyday functioning and mortality in persons who are homeless or precariously housed.

METHOD

Participants were 407 community-dwelling adults, followed for up to 13 years. Neurocognition was assessed at baseline and IIV dispersion was derived using a battery of standardized tests. Functional outcomes (social, physical) were obtained at baseline and last follow-up. Mortality was confirmed with Coroner's reports and hospital records (N  = 103 deaths). Linear regressions were used to predict current social and physical functioning from IIV dispersion. Repeated measures Analysis of Covariance were used to predict long-term change in functioning. Cox regression models examined the relation between IIV dispersion and mortality. Covariates included global cognition (i.e. mean-level performance), age, education, and physical comorbidities.

RESULTS

Higher IIV dispersion predicted poorer current physical functioning (B = -0.46 p = .010), while higher global cognition predicted better current (B  = 0.21, p = .015) and change in social functioning over a period of up to 13 years (F  = 4.23, p = .040). Global cognition, but not IIV dispersion, predicted mortality in individuals under 55 years old (HR = 0.50, p = .013).

CONCLUSIONS

Our findings suggest that indices of neurocognitive functioning (i.e. IIV dispersion and global cognition) may be differentially related to discrete dimensions of functional outcomes in an at-risk population. IIV dispersion may be a complimentary marker of emergent physical health dysfunction in precariously housed adults and may be best used in conjunction with traditional neuropsychological indices.

Association of the Combination of Moderate-to-Vigorous Physical Activity and Sleep Quality with Physical Frailty

BACKGROUND

The association of the individual and combined effects of moderate-to-vigorous physical activity (MVPA) and sleep quality with physical frailty in community-dwelling older adults is still unknown.

SUBJECTS AND METHODS

A cross-sectional study was conducted with a sample of older adults who had not required nursing care or support services. Physical frailty was assessed using Liu's definition based on Fried's concept. MVPA was measured by a triaxial accelerometer, and individuals who met either moderate physical activity (MPA) for ≥300 min/week, vigorous physical activity (VPA) for ≥150 min/week, or both were defined as "MVA+". "SLP+" was defined as a Pittsburgh Sleep Quality Index score of <5.5 points.

RESULTS

A total of 811 participants were included in the final analysis. After adjusting for the multivariable confounding factors, the odds ratios (ORs) and 95% confidence intervals (CIs) for physical pre-frailty and frailty in the MVA-SLP+ (OR, 2.56; 95%CI, 1.80-3.62) and the MVA-SLP- group (OR, 3.97; 95%CI, 2.33-6.74) were significantly higher compared with the MVA+SLP+ group.

CONCLUSION

Community-dwelling older adults who did not meet the MVPA criteria, regardless of sleep quality, had a higher prevalence of physical frailty.

Preoperative frailty screening in elderly patients with non-small cell lung cancer surgery: an essential step for a good surgical outcome

INTRODUCTION

Non-small cell lung cancer (NSCLC) is a disease commonly diagnosed in the elderly, often in advanced stages. However, elderly patients with lung cancer can benefit from surgery, provided that postoperative risks are assessed appropriately before surgery. Frailty is a measure of age-related impaired functional status and a predictor of mortality and morbidity. However, its importance as a preoperative marker is not well defined.

AREAS COVERED

This systematic review discusses the importance of preoperative frailty screening in elderly patients with NSCLC. A literature search was performed on the MEDLINE database in June 2023, and relevant studies on frailty or preoperative assessment of NSCLC which were published between 2000 and 2023 were retained and discussed in this review.

EXPERT OPINION

Among the types of existing methods used to assess frailty those on the geriatric assessment seem to be the most appropriate; however, they are unable to fully capture the 'surgical' frailty; thus, other instruments should be developed and validated in NSCLC.

The Association of Frailty and Neighborhood Disadvantage with Emergency Department Visits and Hospitalizations in Older Adults

BACKGROUND

Risk stratification and population management strategies are critical for providing effective and equitable care for the growing population of older adults in the USA. Both frailty and neighborhood disadvantage are constructs that independently identify populations with higher healthcare utilization and risk of adverse outcomes.

OBJECTIVE

To examine the joint association of these factors on acute healthcare utilization using two pragmatic measures based on structured data available in the electronic health record (EHR).

DESIGN

In this retrospective observational study, we used EHR data to identify patients aged ≥ 65 years at Atrium Health Wake Forest Baptist on January 1, 2019, who were attributed to affiliated Accountable Care Organizations. Frailty was categorized through an EHR-derived electronic Frailty Index (eFI), while neighborhood disadvantage was quantified through linkage to the area deprivation index (ADI). We used a recurrent time-to-event model within a Cox proportional hazards framework to examine the joint association of eFI and ADI categories with healthcare utilization comprising emergency visits, observation stays, and inpatient hospitalizations over one year of follow-up.

KEY RESULTS

We identified a cohort of 47,566 older adults (median age = 73, 60% female, 12% Black). There was an interaction between frailty and area disadvantage (P = 0.023). Each factor was associated with utilization across categories of the other. The magnitude of frailty's association was larger than living in a disadvantaged area. The highest-risk group comprised frail adults living in areas of high disadvantage (HR 3.23, 95% CI 2.99-3.49; P < 0.001). We observed additive effects between frailty and living in areas of mid- (RERI 0.29; 95% CI 0.13-0.45; P < 0.001) and high (RERI 0.62, 95% CI 0.41-0.83; P < 0.001) neighborhood disadvantage.

CONCLUSIONS

Considering both frailty and neighborhood disadvantage may assist healthcare organizations in effectively risk-stratifying vulnerable older adults and informing population management strategies. These constructs can be readily assessed at-scale using routinely collected structured EHR data.

Association between Active Hobby before Hospitalization and Frailty at Discharge in Patients with Acute Cardiovascular Disease

Objectives

It is essential to identify the factors that reduce the risk of frailty at discharge in patients with cardiovascular disease. We sought to verify the association between pre-admission hobbies and frailty at discharge in patients hospitalized for acute cardiovascular diseases.

Methods

We retrospectively analyzed the cases of the 269 patients admitted to our hospital with cardiovascular diseases, excluding those who required assistance with activities of daily living before admission or had missing data on hobbies or frailty. The patients' pre-admission hobbies (if any) were recorded, and the patients were then classified into the no-hobby group, inactive-hobby group, or active-hobby group. Frailty was assessed using the Cardiovascular Health Study criteria (Japanese version) on the day before discharge. We conducted a multinomial logistic regression analysis to investigate the relationship between hobbies and frailty.

Results

Compared with the no-hobby group, the inactive-hobby group did not show a significantly lower odds ratio (OR) for pre-frailty and frailty. In contrast, the active-hobby group showed a significantly lower OR for pre-frailty and frailty even after adjustment (OR: 0.41, 95% confidence interval: 0.17-0.90). Regarding the components of frailty, the active-hobby group had lower ORs for slow gait speed, exhaustion, and low physical activity relative to the no-hobby group.

Conclusions

Even if patients had hobbies before admission, if those hobbies were non-active, they did not reduce the risk of frailty, suggesting the need for reconsidering rehabilitation approaches during hospitalization.

Frailty and Survivability of Polish Caucasian Nonagenarians and Centenarians

Frailty is a major geriatric problem leading to an increased risk of disability and death. Prevention, identification, and treatment of frailty are important challenges in gerontology and public health. The study aimed to estimate the prevalence of the frailty phenotype (FP) among the oldest-old Polish Caucasians and investigate the relationship between the FP and mortality. Baseline data were collected from 289 long-lived individuals, including 87 centenarians and 202 subjects aged 94-99. Mortality was obtained from population registers over the following 5 years. Sixty percent of subjects were classified as frail, 33% as prefrail, and 7% as robust. Frailty was more common in women than men and among centenarians than nonagenarians. During the 5-year observation period, 92.6% of the frail women and all frail men died, while mortality rates were lower among prefrail, 78.8% and 66.7%, and robust individuals, 60% and 54.5%, respectively. In the survival analysis, frailty was the strongest negative risk factor: HR = 0.328 (95% CI: 0.200-0.539). The inability to perform handgrip strength measurement was an additional predictor of short survival. In conclusion, the FP is prevalent in nonagenarians and centenarians and correlates with lower survivability. Future studies should address differences between unavoidable age-associated frailty and reversible disability in long-lived individuals.

Diet Quality and Incident Frailty in Adults 65 Years or Older: The Israeli Longitudinal Study on Aging

OBJECTIVE

To prospectively examine the association between diet quality and frailty incidence in the oldest-old age group.

METHODS

We studied an older adult (65+ years) cohort participating in the Israeli National Health and Nutrition Survey of Older Adults in 2005-2006 (T1 [N=1799]). Survivors of T1 were contacted, and between 2017 and 2019, an extensive interview and a functional assessment were conducted (T2) of 604 past participants. A 24-hour dietary recall, assessed at T1, was used to calculate the Healthy Eating Index (HEI-2015) score. A frailty index based on an accumulation of deficits, including clinical, functional, and cognitive measures, was computed. Frail participants at T1 were excluded from the analysis. Logistic regression models were constructed to assess the association of HEI-2015 score with frailty incidence. Inverse probability weighting was used to minimize selection bias due to attrition.

RESULTS

Of the 479 T2 participants analyzed (mean [SD] age, 84 [5] years; 50% women), 225 (46%) were classified as frail. Frail participants were older, were less educated, and had a lower household income and a higher comorbidity burden at baseline than non-frail participants. After adjustment for sociodemographic and lifestyle factors, a higher HEI-2015 score was associated with decreased odds of incident frailty (odds ratio, 0.57 [95% CI, 0.35 to 0.91] for the upper tertile and 0.66 [95% CI, 0.42 to 1.06] for the middle tertile compared with the lower tertile; Ptrend=.02).

CONCLUSION

In this cohort study of oldest-old participants, improved diet quality was inversely associated with frailty incidence in a dose-dependent manner.

Frailty and Environmental Attributes in Older Adults: Insight from an Ecological Model

Many studies on frailty have primarily focused on individual-level risk factors such as demographics and lifestyle. While guidelines for frailty management recommend modifications to an individual's lifestyle, their lifestyle behaviors are significantly influenced by their surroundings. Recently, the association between frailty and environmental attributes has drawn attention as a result of the increase in evidence that multiple factors affect health conditions and behaviors associated with frailty. These findings can be organized based on an ecological model involving five nested levels that influence an individual's behaviors, namely, an intrapersonal/individual core (age, education, and attitude), an interpersonal level (persons and groups), an organizational/institutional level (organization and workplace), a community level (natural, built, and social environments), and a system/public policy level (public policies from local to national). This study reviewed possible factors associated with frailty from the onset and its progression at each level of the ecological model and their implications regarding frailty prevention. Additionally, we introduce a policy-level approach for frailty prevention in Japan-which encourages residents to engage in the local society by participating in community places or groups that are referred to as "Kayoi-no-ba"-and aggregate its status from a government report. This perspective on community building is consistent with the concept of an ecological model. However, few studies have verified the effects of policy- or system-level approaches on disability and frailty prevention. Further studies from an ecological perspective are needed to fulfill multilevel interventions for frailty prevention.

Cancer mortality and competing causes of death in older adults with cancer: A prospective, multicentre cohort study (ELCAPA-19)

BACKGROUND

In older patients with cancer, comorbidities compete with cancer for cause of death. The objectives were to evaluate cancer mortality and factors associated, according to metastatic status.

METHODS

Between 2007 and 2014, patients with cancer aged ≥70 referred for pre-therapeutic geriatric assessment (GA) were included through the ELCAPA prospective cohort study. The underlying cause of death was defined according to the International Classification of Diseases, 10th Revision. The World Health Organisation definition was used to categorise the cause of death as cancer versus another disease (e.g. cardiovascular disease, infectious disease, etc.) Competing risk models were used.

RESULTS

Mean (SD) age of the 1445 included patients was 80.2 (5.8) and 48% were women. Most common tumour sites were colorectal (19%), breast (17%) and urinary (15%); 773 patients (49%) had metastases. After a 34-month median follow-up, 706 cancer deaths were observed among 843 deaths. The 6-month and 3-year cancer mortality rates (95% CI) were 12% (9-15) and 34% (29-38) for non-metastatic patients and 43% (39-47) and 79% (75-82) for metastatic patients, respectively. Dependency in activities of daily living and comorbidities were associated with 6-month and 3-year cancer mortality in non-metastatic (adjusted subhazard ratio [aSHR] = 1.68 [0.99-2.85] and 1.69 [1.16-2.45]; and 1.98 [1.08-3.63] and 3.38 [1.47-7.76], respectively) and metastatic patients (aSHR = 2.81 [2.01-3.93] and 2.95 [2.14-4.07]; and 1.63 [1.18-2.25] and 2.06 [1.39-3.05], respectively). Impaired Timed-Get-Up-and-Go test was associated with 6-month and 3-year cancer mortality in metastatic patients (aSHR = 1.5 [1.06-2.12] and 1.38 [1.06-1.81], respectively). Obesity was negatively associated with 3-year cancer death in non-metastatic (aSHR = 0.53 [0.29-0.97]) and metastatic patients (aSHR = 0.71 [0.51-1.00]).

CONCLUSIONS

The majority of older adults with cancer referred for pre-therapeutic GA die from cancer. Geriatric parameters are independently associated with cancer mortality and should be considered for prognosis assessment, decision-making and care.

Longitudinal Changes of Cognition and Frailty With All-Cause and Cause-Specific Mortality in Chinese Older Adults: An 11-Year Cohort Study

Background and Objectives

Physical function deterioration is always accompanied by a cognitive decline in older adults. However, evidence is lacking for the long-term simultaneous changing patterns of cognition and physical frailty and their associations with mortality among older adults.

Research Design and Methods

This study included 8,231 adults aged ≥65 with a baseline and at least one follow-up assessment of both cognition and physical frailty from the 2007-2018 Chinese Longitudinal Healthy Longevity Survey. Physical frailty (FRAIL phenotype) and cognition (Mini-Mental State Examination) were applied. Group-based joint trajectory modeling was used to fit the joint trajectories of cognition and physical frailty. Cox proportional hazards model was used to evaluate the trajectory-mortality associations.

Results

Three distinct joint trajectories were identified: no joint progression (34.4%), moderate joint progression (47.0%), and rapid joint progression (18.6%). During a median follow-up of 8.3 years, the rapid joint progression group, compared to the no joint progression, had the highest risk for all-cause mortality (hazard ratio (HR), 3.37 [95% CI: 2.99-3.81]), cardiovascular (CVD) mortality (3.21 [2.08-4.96]) and non-CVD mortality (2.99 [2.28-3.92]), respectively. Joint trajectory was found to be more predictive of mortality as compared to baseline measures of cognition and/or frailty (C-statistic ranged from 0.774 to 0.798). Higher changing rates of cognition and frailty were observed among all-cause decedents compared to CVD and non-CVD decedents over a 45-year span (aged 65-110) before death.

Discussion and Implications

Our study suggested that subjects with the worst cognitive decline and severest physical frailty progression were at the highest risk for all-cause and cause-specific mortality. Our findings expand the limited prior knowledge on the dynamic course of cognition and frailty.

Frailty as a predictor of mortality: a comparative cohort study of older adults in Costa Rica and the United States

BACKGROUND

Frailty is a common condition among older adults that results from aging-related declines in multiple systems. Frailty increases older adults' vulnerability to negative health outcomes, including loss of mobility, falls, hospitalizations, and mortality. The aim of this study is to examine the association between frailty and mortality in older adults from Costa Rica and the United States.

METHODS

This prospective cohort study uses secondary nationally-representative data of community-dwelling older adults from the Costa Rican Longevity and Healthy Aging Study (CRELES, n = 1,790) and the National Health & Aging Trends Study (NHATS, n = 6,680). Frailty status was assessed using Physical Frailty Phenotype, which includes the following five criteria: shrinking, exhaustion, low physical activity, muscle weakness, and slow gait. We used Cox proportional hazard models to examine the association between frailty and all-cause mortality, including sociodemographic characteristics and health behaviors as covariates in the models. Mortality follow-up time was right censored at 8 years from the date at baseline interview.

RESULTS

The death hazard for frail compared to non-frail older adults was three-fold in Costa Rica (HR = 3.14, 95% CI: 2.13-4.62) and four-fold in the White US (HR = 4.02, 95% CI: 3.04-5.32). Older age, being male, and smoking increased mortality risk in both countries. High education was a protective factor in the US, whereas being married/in union was a protective factor in Costa Rica. In the US, White older adults had a lower risk of death compared to all other races and ethnicities.

CONCLUSIONS

Results indicate that frailty can have a differential impact on mortality depending on the country. Access to universal health care across the life course in Costa Rica and higher levels of stress and social isolation in the US may explain differences observed in end-of-life trajectories among frail older adults.

Advantages and Disadvantages of Random Forest Models for Prediction of Hip Fracture Risk Versus Mortality Risk in the Oldest Old

Targeted fracture prevention strategies among late-life adults should balance fracture risk versus competing mortality risk. Models have previously been constructed using Fine-Gray subdistribution methods. We used a machine learning method adapted for competing risk survival time to evaluate candidate risk factors and create models for hip fractures and competing mortality among men and women aged 80 years and older using data from three prospective cohorts (Study of Osteoporotic Fractures [SOF], Osteoporotic Fracture in Men study [MrOS], Health Aging and Body Composition study [HABC]). Random forest competing risk models were used to estimate absolute 5-year risk of hip fracture and absolute 5-year risk of competing mortality (excluding post-hip fracture deaths). Models were constructed for both outcomes simultaneously; minimal depth was used to rank and select variables for smaller models. Outcome specific models were constructed; variable importance was used to rank and select variables for inclusion in smaller random forest models. Random forest models were compared to simple Fine-Gray models with six variables selected a priori. Top variables for competing risk random forests were frailty and related components in men while top variables were age, bone mineral density (BMD) (total hip, femoral neck), and frailty components in women. In both men and women, outcome specific rankings strongly favored BMD variables for hip fracture prediction while frailty and components were strongly associated with competing mortality. Model discrimination for random forest models varied from 0.65 for mortality in women to 0.81 for hip fracture in men and depended on model choice and variables included. Random models performed slightly better than simple Fine-Gray model for prediction of competing mortality, but similarly for prediction of hip fractures. Random forests can be used to estimate risk of hip fracture and competing mortality among the oldest old. Modest gains in performance for mortality without hip fracture compared to Fine-Gray models must be weighed against increased complexity. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

Racial, Ethnic, and Socioeconomic Differences in a Deficit Accumulation Frailty Index in the Multiethnic Cohort Study

BACKGROUND

Frailty status has been sparsely studied in some groups including Native Hawaiians and Asian Americans.

METHODS

We developed a questionnaire-based deficit accumulation frailty index (FI) in the Multiethnic Cohort (MEC) and examined frailty status (robust, FI 0 to <0.2, prefrail, FI 0.2 to <0.35, and frail FI ≥ 0.35) among 29 026 men and 40 756 women.

RESULTS

After adjustment for age, demographic, lifestyle factors, and chronic conditions, relative to White men, odds of being frail was significantly higher (34%-54%) among African American, Native Hawaiian, and other Asian American men, whereas odds was significantly lower (36%) in Japanese American men and did not differ in Latino men. However, among men who had high school or less, none of the groups displayed significantly higher odds of prefrail or frail compared with White men. Relative to White women, odds of being frail were significantly higher (14%-33%) in African American and Latino women, did not differ for other Asian American women and lower (14%-36%) in Native Hawaiian and Japanese American women. These racial and ethnic differences in women were observed irrespective of education. Risk of all-cause mortality was higher in prefrail and frail men than robust men (adjusted hazard ratio [HR] = 1.69, 1.59-1.81; HR = 3.27, 3.03-3.53); results were similar in women. All-cause mortality was significantly positively associated with frailty status and frailty score across all sex, race, and ethnic groups.

CONCLUSIONS

Frailty status differed significantly by race and ethnicity and was consistently associated with all-cause mortality. The FI may be a useful tool for aging studies in this multiethnic population.

Frailty at death: An examination of multiple causes of death in four low mortality countries in 2017

BACKGROUND

The increasing prevalence of frailty in aging populations represents a major social and public health challenge which warrants a better understanding of the contribution of frailty to the morbid process.

OBJECTIVE

To examine frailty-related mortality as reported on the death certificate in France, Italy, Spain and the United States in 2017.

METHODS

We identify frailty at death for the population aged 50 years and over in France, Italy, Spain and the United States. We estimate the proportions of deaths by sex, age group and country with specific frailty-related ICD-codes on the death certificate 1) as the underlying cause of death (UC), 2) elsewhere in Part I (sequence of diseases or conditions or events leading directly to death), and 3) anywhere in Part II (conditions that do not belong in Part I but whose presence contributed to death).

RESULTS

The age-standardized proportion of deaths with frailty at ages 50 and over is highest in Italy (25.0%), then in France (24.1%) and Spain (17.3%), and lowest in the United States (14.0%). Cross-country differences are smaller when frailty-related codes are either the underlying cause of the death or reported in Part II. Frailty-related mortality increases with age and is higher among females than males. Dementia is the most frequently reported frailty-related code.

CONCLUSIONS

Notable cross-country differences were found in the prevalence and the type of frailty-related symptoms at death even after adjusting for differential age distributions.

The role of lifestyle in the association between frailty and all-cause mortality amongst older adults: a mediation analysis in the UK Biobank

OBJECTIVE

frailty is a syndrome characterised by increased vulnerability to stressors, which manifests as higher death risk. Whilst guidelines for frailty management usually entails lifestyle modifications (e.g. physical exercise, diet), the mediating role of lifestyle on the excess mortality associated with frailty is unclear. This study estimates the death risk due to frailty that could be avoided with a healthy lifestyle in older adults.

SUBJECTS AND METHODS

we analysed data from 91,906 British individuals aged ≥60 years recruited between 2006 and 2010. At baseline, frailty was identified according to Fried's phenotype, and a four-item Healthy Lifestyle Index (HLS) was calculated based on physical activity, diet, smoking and alcohol consumption. Mortality was ascertained from baseline through 2021. A mediation analysis under the counterfactual framework was performed adjusting for the main confounders.

RESULTS

during a median follow-up of 12.5 years, 9,383 deaths occurred. Frailty was directly associated with all-cause mortality (hazard ratio: 2.30 [95% confidence interval {CI} 2.07, 2.54]), and inversely associated with the HLS (ß: -0.45 points [-0.49, -0.40]). The hazard ratio [95%CI] for the direct effect of frailty on mortality was 2.12 [1.91, 2.34], whilst for the indirect effect (mediated by HLS) was 1.08 [1.07, 1.10]. The mediated proportion of HLS on mortality was 13.55% [11.26, 16.20], with physical activity having the highest proportion amongst the four HLS items (7.69% [5.00, 10.40]).

CONCLUSIONS

a healthy lifestyle partly mediates the association between frailty and mortality in British older adults. Since this was an exploratory mediation analysis, these results should be specifically tested in future research.

Mortality Risks after Two Years in Frail and Pre-Frail Older Adults Admitted to Hospital

BACKGROUND

Frailty is characterized by a progressive decline in the physiological functions of multiple body systems that lead to a more vulnerable condition, which is prone to the development of various adverse events, such as falls, hospitalization, and mortality. This study aims to determine whether frailty increases mortality compared to pre-frailty and to identify variables associated with a higher risk of mortality.

MATERIALS

Two cohorts, frail and pre-frail subjects, are evaluated according to the Fried phenotype. A complete examination of frailty, cognitive status, comorbidities and pharmacology was carried out at hospital admission and was extracted through electronic health record (EHR). Mortality was evaluated from the EHR.

METHODS

Kaplan-Meier estimates of survival probability functions were calculated at two years censoring time for frail and pre-frail cohorts. The log-rank test assessed significant differences between survival probability functions. Significant variables for frailty (p < 0-05) were extracted by independent sample t-test. Further selection was based on variable significance found in multivariate logistic regression discrimination between frail and pre-frail subjects. Cox regression over univariate t-test-selected variables was calculated to identify variables associated with higher proportional hazard risks (HR) at two years.

RESULTS

Frailty is associated with greater mortality at two years censoring time than pre-frailty (log-rank test, p < 0.0001). Variables with significant (p < 0.05) association with mortality identified in both cohorts (HR 95% (CI in the frail cohort) are male sex (0.44 (0.29-0.66)), age (1.05 (1.01-1.09)), weight (0.98 (0.96-1.00)), and use of proton-pump inhibitors (PPIs) (0.60 (0.41-0.87)). Specific high-risk factors in the frail cohort are readmission at 30 days (0.50 (0.33-0.74)), SPPB sit and stand (0.62 (0.45-0.85)), heart failure (0.67 (0.46-0.98)), use of antiplatelets (1.80 (1.19-2.71)), and quetiapine (0.31 (0.12-0.81)). Specific high-risk factors in the pre-frail cohort are Barthel's score (120 (7.7-1700)), Pfeiffer test (8.4; (2.3-31)), Mini Nutritional Assessment (MNA) (1200 (18-88,000)), constipation (0.025 (0.0027-0.24)), falls (18,000 (150-2,200,000)), deep venous thrombosis (8400 (19-3,700,000)), cerebrovascular disease (0.01 (0.00064-0.16)), diabetes (360 (3.4-39,000)), thyroid disease (0.00099 (0.000012-0.085)), and the use of PPIs (0.062 (0.0072-0.54)), Zolpidem (0.000014 (0.0000000021-0.092)), antidiabetics (0.00015 (0.00000042-0.051)), diuretics (0.0003 (0.000004-0.022)), and opiates (0.000069 (0.00000035-0.013)).

CONCLUSIONS

Frailty is associated with higher mortality at two years than pre-frailty. Frailty is recognized as a systemic syndrome with many links to older-age comorbidities, which are also found in our study. Polypharmacy is strongly associated with frailty, and several commonly prescribed drugs are strongly associated with increased mortality. It must be considered that frail patients need coordinated attention where the diverse specialist taking care of them jointly examines the interactions between the diversity of treatments prescribed.

Frailty and all-cause and cause-specific mortality in Japan

BACKGROUND

In aging societies, there is an increasing focus on the concept of frailty. However, there is no consistent means to assess this concept. We assessed frailty using the Kihon Checklist (KCL), which is widely used in Japan, and examined the association between frailty and all-cause and cause-specific mortality in Japan, the most aged society in the world.

METHODS

This was a retrospective cohort study, and we analyzed 43,312 participants aged ≥ 65 years who were enrolled in basic health checkups in Okayama City, Japan. We defined the frailty status of the participants using the KCL. To assess the association of frailty status with all-cause and cause-specific mortality, we used cause-specific Cox proportional hazard models to estimate hazard ratios (HRs), adjusting for individual potential confounders. Mean follow-up time was 9.3 years.

RESULTS

The fully adjusted HR for all-cause mortality was 1.34 (95% confidence interval [CI]: 1.27-1.41) for the prefrail group and 2.22 (95% CI: 2.11-2.33) for the frail group. A similar pattern was observed for cardiovascular disease, respiratory disease, and cancer mortality. Younger people (65-74 years) and women tended to have higher effect estimates than older people (≥ 75 years) and men.

CONCLUSION

Prefrailty and frailty can increase the risk of both all-cause and cause-specific mortality. Our study suggests that to support frail patients, it could be effective to focus on the prevention and management of cardiovascular and respiratory disease, and that the KCL may be useful as a method of screening for frailty.

The national burden of frailty and disproportionate distribution of its components-the predominance of slow gait speed: a 2018-19 face-to-face epidemiologic assessment representative of population of older Poles

BACKGROUND

The prevalence of frailty and its components may be affected by age, diseases and geriatric deficits. However, the current operational definition of frailty assigns equal weight to the five components of frailty.

AIMS

To perform a population-based assessment of physical frailty, its prevalence, and distribution of its components across different age, disease and deficit spectrum.

METHODS

From 2018 to 2019, we conducted a face-to-face cross-sectional assessment of a representative sample of older Poles. We obtained data on frailty components, chronic disease burden, and prevalence of particular diseases and geriatric deficits. We calculated weighted population estimates, representative of 8.5 million older Poles, of prevalence of frailty and its components across the disease burden, associated with the particular diseases and the geriatric deficits present.

RESULTS

Of 10,635 screened persons ≥ 60 years, 5987 entered the face-to-face assessment. Data of 5410 have been used for the present analysis. Seventy-two percent of the population are burdened with at least one frailty component. The estimated weighted population prevalence (95% CI) of frailty was 15.9% (14.6-17.1%), and of pre-frailty 55.8% (53.3-58.2%). Slow gait speed predominated across disease burden, specific diseases, geriatric deficits and the age spectrum. Overall, the prevalence of slow gait speed was 56.3% (52.7-60.0%), followed by weakness 26.9% (25.4-28.4%), exhaustion 19.2% (17.6-20.8%), low physical activity 16.5% (14.8-18.3%), and weight loss 9.4% (8.4-10.3%).

CONCLUSIONS

Slow gait speed predominates among the components of frailty in older Poles. This may affect the component-tailored preventive and therapeutic actions to tackle frailty.

Transitions in Frailty and 4-Year Mortality Risk in Taiwan Longitudinal Study on Aging

OBJECTIVES

To explore the associations of (1) the frailty phenotype or frailty index transition with cause-specific mortality, and (2) different combinations of transition in frailty phenotype and frailty index with all-cause mortality.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Data from 3529 respondents aged >50 years who completed the 1999 and 2003 surveys of the Taiwan Longitudinal Study on Aging were analyzed.

METHODS

Cox regression and subdistribution hazard models were constructed to investigate frailty phenotype or frailty index transitions (by categories of frailty phenotype, absolute and percentage changes in frailty index, and combined categories of the 2 measurements) and subsequent 4-year all-cause and cause-specific mortality, respectively.

RESULTS

Among the frailty phenotype transition groups, the improved frailty group had overall mortality risk comparable to that of the maintained robustness/prefrailty group [hazard ratio (HR): 0.9; 95% CI: 0.7-1.2] and lower risk of mortality due to organ failure (HR: 0.4; 95% CI: 0.2-0.8; P = .015), whereas the worsened frailty group had the highest risk of all-cause mortality and death from infection, malignancy, cardiometabolic/cerebrovascular diseases, and other causes (HR: 1.8-3.7; all P < .03). The rapidly increased frailty index group had significantly higher all-cause and every cause-specific mortality than the decreased frailty index group (HR: 1.8-7.7; all P < .05). When frailty phenotype and frailty index transition groups were combined, participants with worsened frailty/rapidly increased frailty index had increased risk under the same frailty index/frailty phenotype transition condition, particularly for large changes in each factor (HR: 1.5-2.2; P < .01 for worsened frailty; 1.7-4.5, P < .03 for rapidly increased frailty index).

CONCLUSIONS AND IMPLICATIONS

We found that considering both frailty phenotype and frailty index provided best mortality prediction. These associations were independent of baseline frailty status and comorbidities. Nevertheless, even capturing transitions in frailty phenotype or frailty index only can provide good mortality prediction, which supported adopting these approaches in different clinical settings.

Effects of systemic inflammation and frailty on survival in elderly cancer patients: Results from the INSCOC study

Background

Frailty and systemic inflammation are parameters, which are easy to evaluate, can be used to predict disease outcomes, and are potentially modifiable. The combination of frailty and inflammation-based data may help identify elderly cancer patients predisposed to adverse clinical outcomes. The aim of this study was to examine the association of systemic inflammation and frailty at admission, and to determine whether these risk factors interact and may predict the survival of elderly cancer patients.

Methods

A prospective Investigation on Nutrition Status and Clinical Outcome of Common Cancers (INSCOC) with 5,106 elderly cancer patients admitted from 2013 through 2020 was included in this study. The primary marker of inflammation was the neutrophil-to-lymphocyte ratio (NLR), with the reference group having NLR<3, which indicated no inflammation. Frailty was assessed using the FRAIL scale, and patients with≥3 positives out of a total of five components were assumed to be frail. The primary outcome was all-cause mortality. We classified participants according to the presence (or absence) of frailty and high inflammation and assessed their association with overall survival using the Cox proportional hazards models adjusted for demographic, tumor, and treatment factors.

Results

Among the 5,106 patients enrolled in the study, 3396 individuals (66.51%) were male and the mean( ± SD) age at diagnosis was 70.92( ± 5.34). Over a median of 33.5 months follow-up, we observed 2,315 deaths. Increasing NLR was associated with frailty (compared with NLR<3, odds ratio=1.23, 95%CI=1.08-1.41 for NLR≥3). An NLR≥3 and frailty independently predicted the overall survival [hazard ratio(HR)=1.35, 95%CI=1.24-1.47 and HR=1.38, 95%CI=1.25-1.52, respectively). Patients with both frailty and NLR≥3 had the lowest overall survival(HR=1.83, 95%CI=1.59-2.04) than patients with no risk factors. The mortality rate increased with the presence of the frailty components.

Conclusions

Systemic inflammation was positively associated with frailty. Frail elderly cancer patients with elevated systemic inflammation had low survival rate.

Highest Achievable Outcomes for Patients Undergoing Cervical Deformity Corrective Surgery by Frailty

BACKGROUND

Frailty is influential in determining operative outcomes, including complications, in patients with cervical deformity (CD).

OBJECTIVE

To assess whether frailty status limits the highest achievable outcomes of patients with CD.

METHODS

Adult patients with CD with 2-year (2Y) data included. Frailty stratification: not frail (NF) <0.2, frail (F) 0.2 to 0.4, and severely frail (SF) >0.4. Analysis of covariance established estimated marginal means based on age, invasiveness, and baseline deformity, for improvement, deterioration, or maintenance in Neck Disability Index (NDI), Modified Japanese Orthopaedic Association (mJOA), and Numerical Rating Scale Neck Pain.

RESULTS

One hundred twenty-six patients with CD included 29 NF, 83 F, and 14 SF. The NF group had the highest rates of deterioration and lowest rates of improvement in cervical Sagittal Vertical Axis and horizontal gaze modifiers. Two-year improvements in NDI by frailty: NF: -11.2, F: -16.9, and SF: -14.6 (P = .524). The top quartile of NF patients also had the lowest 1-year (1Y) NDI (7.0) compared with F (11.0) and SF (40.5). Between 1Y and 2Y, 7.9% of patients deteriorated in NDI, 71.1% maintained, and 21.1% improved. Between 1Y and 2Y, SF had the highest rate of improvement (42%), while NF had the highest rate of deterioration (18.5%).

CONCLUSION

Although frail patients improved more often by 1Y, SF patients achieve most of their clinical improvement between 1 and 2Y. Frailty is associated with factors such as osteoporosis, poor alignment, neurological status, sarcopenia, and other medical comorbidities. Similarly, clinical outcomes can be affected by many factors (fusion status, number of pain generators within treated levels, integrity of soft tissues and bone, and deformity correction). Although accounting for such factors will ultimately determine whether frailty alone is an independent risk factor, these preliminary findings may suggest that frailty status affects the clinical outcomes and improvement after CD surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

PROSPERO (CRD42021276021).

The role of frailty in the association between depression and fall risk among older adults

OBJECTIVES

Although there is a recognized association between depression and greater fall risk among older adults, the mechanisms explaining this association are unclear. This study evaluated the role of frailty, a common geriatric syndrome, in determining greater risk of falls among older adults with depression.

METHOD

We used longitudinal data from three biennial waves of the Health and Retirement Study (HRS; 2010-2014). The sample included community-dwelling survey respondents age ≥ 65 who participated in objective physiological measures. Major Depression (MD) was measured using Composite International Diagnostic Interview for depression short form. Frailty was measured using criteria outlined in the frailty phenotype model. Causal mediation analysis was used to differentiate the direct effect of depression and indirect effect mediated by frailty on falls, fall injuries, and multiple falls.

RESULTS

Major depression was associated with significantly greater odds of experiencing a fall (OR: 1.91; 95% CI: 1.31, 2.77), fall injury (OR: 1.86; 95% CI: 1.17, 2.95), and multiple falls (OR: 2.26; 95% CI: 1.52, 3.37) over a two-year period. Frailty was a significant mediator of the effects of depression on falls and multiple falls, accounting for approximately 18.9% and 21.3% of the total effects, respectively. We found no evidence of depression-frailty interaction. Sensitivity analyses showed that results were robust to unmeasured confounding and alternative operationalizations of depression.

CONCLUSION

Frailty explains a significant proportion of increased likelihood of falls among older adults with depression. Treatment and management of frailty symptoms may be an important components of fall prevention among older adults with depression.

Sarc-frailty: towards an integrated view of ageing

OBJECTIVES

Sarcopenia and frailty have both been related to adverse events in ageing, but have long been studied in parallel. The purpose of this study was to provide a better depiction of ageing by taking the advantages of both entities.

STUDY DESIGN

2532 participants were enrolled from the National Health and Nutrition Examination Survey 1999-2002. A new diagnostic entity, sarc-frailty, was established by merging the diagnostic elements of both sarcopenia and frailty.

MAIN OUTCOME MEASURES

Cox proportional hazard models, Kaplan-Meier curve, and receiver operating characteristic (ROC) curve analysis were utilized to compare the hazard ratios and predictive power in relation to mortality of sarcopenia, frailty, and sarc-frailty. Two different classification strategies, categorical and scoring, were used as alternative assessment methods.

RESULTS

The median follow-up duration was 67.49 months, and no participants were lost to follow-up. ROC analysis revealed the highest area under curves (AUC) in sarc-frailty by both categorical and scoring classification (AUC = 0.660, p value <0.001 and AUC = 0.697, p value <0.001, respectively), indicating the best predictive ability in relation to mortality. Kaplan-Meier analysis also demonstrated the shortest overall survival for sarc-frailty with both classifications (p value both <0.001). In addition, hazard ratios (HRs) of sarc-frailty with both classifications were higher than their counterparts for sarcopenia and frailty (HR = 12.599, 95 % CI = 7.780 to 20.403, p < 0.001 by categorical method, and HR = 20.121, 95 % CI = 8.101 to 49.973, p < 0.001 by scoring classification). Moreover, the scoring classification revealed a more delicate hierarchical structure of mortality levels than the categorical classification.

CONCLUSIONS

Sarc-frailty had a better predictive ability in relation to mortality. Considering that ageing well is a holistic health-care issue, our new entity, along with the scoring method, provides clinicians with more effective tools in geriatric assessment.

Associations between loneliness and frailty among older adults: Evidence from the China Health and Retirement Longitudinal Study

Background

Previous studies have demonstrated the associations between loneliness and frailty in late life. However, there is a lack of consensus on the direction of the relationship. The present study aimed to examine the interdependencies between loneliness and frailty over time.

Methods

Data on participants aged 60 years old and above were collected from the 2011, 2013, and 2015 samples of the China Health and Retirement Longitudinal Study (CHARLS). Loneliness was measured by a single question from the Centre for Epidemiological Studies Depression scale, and frailty was assessed by the Physical Frailty Phenotype (PFP) scale. Cross-lagged panel models were utilized to examine the potential bidirectional relationship between loneliness and frailty.

Results

Reciprocal associations were found between loneliness and frailty. Furthermore, we found that baseline frailty and early change in frailty had a significant predictive effect on late change in loneliness. Higher baseline loneliness in older adults may create a potentially vicious cycle that influenced early change in frailty and continued to cause late change in loneliness.

Conclusion

A bidirectional relationship may exist between loneliness and frailty among older Chinese adults over 60 years old. Lonely older adults should be alerted to the potential self-reinforcing cycle of loneliness that affects their health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03044-0.

Association of frailty with fall events in older adults: A 12-year longitudinal study in Korea

BACKGROUND

Evidence has shown that frailty is associated with the risk of falls in older people. However, the components of frailty that have the highest association with fall events are largely unknown.

METHODS

This study analyzed panel data from the Korean Longitudinal Study of Aging. We used the Korean Frailty Instrument, which includes domains for social isolation, exhaustion and weakness estimated by grip strength, to assess frailty. Fall event data were collected during follow-up visits.

RESULTS

A total of 3122 community-dwelling adults aged 65 years or older were included at baseline in 2006 and were followed up every 2 years until 2018. The participants with frailty had a higher risk of falls than those without frailty (OR=1.31, 95% CI=1.11-1.54, P = 0.001; fully adjusted model). We found that three components of frailty, namely, social isolation, exhaustion, and weakness, were independently and significantly related to fall events in the unadjusted model. In the fully adjusted model, social isolation and exhaustion were significantly associated with fall events (OR=1.38, 95% CI=1.18-1.61, P < 0.001 and OR=1.28, 95% CI=1.10-1.51, P = 0.006, respectively), and there was no significant association between weakness and the risk of falls (OR=1.11, 95% CI=0.91-1.34, P = 0.307).

CONCLUSIONS AND IMPLICATIONS

Frailty was associated with more fall events in Korean older adults. Social isolation and exhaustion but not weakness were significantly associated with fall events. Our study suggests that interventions should be tailored to older adults with social and psychological frailty.

Prevalence of Undernutrition, Frailty and Sarcopenia in Community-Dwelling People Aged 50 Years and Above: Systematic Review and Meta-Analysis

The world’s population aged ≥65 is expected to rise from one in eleven in 2019 to one in six by 2050. People aged ≥65 are at a risk of undernutrition, frailty, and sarcopenia. The association between these conditions is investigated in a hospital setting. However, there is little understanding about the overlap and adverse health outcomes of these conditions in community-dwelling people. This systematic review aims to quantify the reported prevalence and incidence of undernutrition, frailty, and sarcopenia among older people aged ≥50 living in community dwellings. Searches were conducted using six databases (AMED, CENTRAL, EMBASE, Web of Science, MEDLINE, and CINAHL), and 37 studies were included. Meta-analyses produced weighted combined estimates of prevalence for each condition (Metaprop, Stata V16/MP). The combined undernutrition prevalence was 17% (95% CI 0.01, 0.46, studies n = 5; participants = 4214), frailty was 13% (95% CI 0.11, 0.17 studies n = 28; participants = 95,036), and sarcopenia was 14% (95% CI 0.09, 0.20, studies n = 9; participants = 7656). Four studies reported incidence rates, of which three included data on frailty. Nearly one in five of those aged ≥50 was considered either undernourished, frail, or sarcopenic, with a higher occurrence in women, which may reflect a longer life expectancy generally observed in females. Few studies measured incidence rates. Further work is required to understand population characteristics with these conditions and the overlap between them. PROSPERO registration No. CRD42019153806.

Frailty Among Older Individuals with and without COPD: A Cohort Study of Prevalence and Association with Adverse Outcomes

Rationale

Frailty prevalence estimates among individuals with COPD have varied widely, and few studies have investigated relationships between frailty and adverse outcomes in a COPD population.

Objective(s)

Describe frailty prevalence among individuals with and without COPD and examine associations between frailty and mortality and other adverse outcomes in the next two years.

Methods

This was an observational cohort study using Health and Retirement Study data (2006–2018) of community living individuals ages 50–64 and ≥65 with and without COPD (non-COPD). Frailty (Fried phenotype [5 items], and a modified Frailty Index-Comprehensive Geriatric Assessment [Enhanced FI-CGA] [37 items], and debility (modified BODE Index [4 items]) were assessed. Two-year post-assessment outcomes (mortality, ≥1 inpatient stay, home health and skilled nursing facility (SNF) use) were reviewed in a population matched 3:1 (non-COPD: COPD) on age, sex, race, and year using univariate and multivariate logistic regression (adjusted for morbidities). Area-under-the-curve (AUC) was used to evaluate regressions.

Results

The study included 18,979 survey observations for age 50–64, and 24,162 age ≥65; 7.8% and 12.0% respectively reporting a diagnosis of COPD. Fried phenotype frailty prevalence for age ≥65 was 23.1% (COPD) and 9.4% (non-COPD), and for the Enhanced FI-CGA, 45.9% (COPD) and 22.4% (non-COPD). Two-year mortality for COPD was more than double non-COPD for age 50–64 (95% CI: 3.8–5.9% vs 0.7–1.3%) and age ≥65 (95% CI: 11.9–14.3% vs 5.6–6.6%). Inpatient utilization, home health care use, or at least temporary SNF placement were also more frequent for COPD. Measures were predictive of adverse outcomes. In adjusted models, the Fried phenotype and modified BODE score performed similarly, and both performed better than the Enhanced FI-CGA index. AUC values were higher for morality regressions.

Conclusion

Frailty prevalence among individuals with COPD in this national survey is substantially greater than without COPD, even at pre-retirement (50–64 years). These measures identify patients with increased risk of poor outcomes.

Simple carbohydrate intake and higher risk for physical frailty over 15 years in community-dwelling older adults

Insulin resistance is a major mechanism involved in the onset of physical frailty (PF). Although rich carbohydrate diets may promote insulin resistance, few studies have examined their association with PF risk. This study aimed to investigate the spectrum of carbohydrate exposure, including carbohydrate intake (simple, complex, and total), glycemic load (measure of the diet-related insulin-demand), and adherence to a low-carbohydrate diet with the incident risk of PF in community-dwelling older adults. Baseline carbohydrate exposure was assessed in non-frail participants of the Three-City-Bordeaux cohort using a 24H dietary recall. Over 15 years of follow-up, participants were screened for PF, defined by the FRAIL scale (≥3 criteria out of Fatigue, Resistance, Ambulation, Illnesses, and weight Loss). Associations were estimated using mixed-effects logistic models adjusted for sex, age, education, smoking status, alcohol consumption, depressive symptomatology, global cognitive performances, and protein and energy intakes. The sample included 1,210 participants (62% females, mean age 76 years). Over the follow-up, 295 (24%) incident cases of PF were documented (28% in females, 18% in males). Higher intake of simple carbohydrates was significantly associated with greater odds of incident PF (per 1-SD increased: OR = 1.29; 95% CI = 1.02-1.62), specifically among males (OR = 1.52; 95% CI = 1.04-2.22). No association was observed with complex or total carbohydrate intake, glycemic load, or low-carbohydrate diet. Among the whole carbohydrate exposure, only higher consumption of simple carbohydrates in older age was associated with a higher risk of developing PF. Further studies are required to explore underlying mechanisms.

Early manifestation of gait alterations in the Tg2576 mouse model of Alzheimer's disease

There is strong clinical evidence that multifaceted gait abnormalities may be manifested at early stages of Alzheimer's disease (AD), are related to cognitive decline, and can be used as an early biomarker to identify patients at risk of progressing to full-blown dementia. Despite their importance, gait abnormalities have not been investigated in mouse models of AD, which replicate important aspects of the human disease. The Tg2576 is frequently used in AD research to test therapeutic interventions targeting cellular mechanisms contributing to the genesis of AD. This transgenic mouse strain overexpresses a mutant form of the 695 amino acid isoform of human amyloid precursor protein with K670N and M671L mutations (APPK670/671L) linked to early-onset familial AD. Tg2576 mice exhibit impaired cognitive functions and increased cortical and hippocampal soluble β-amyloid levels starting from 5 months of age and increased insoluble β-amyloid levels and amyloid plaques that resemble senile plaques associated with human AD by 13 months of age. To demonstrate early manifestations of gait dysfunction in this relevant preclinical model, we characterized gait and motor performance in 10-month-old Tg2576 mice and age-matched littermate controls using the semi-automated, highly sensitive, Catwalk XT system. We found that Tg2576 mice at the pre-plaque stage exhibited significantly altered duty cycle and step patterns and decreased stride length and stride time. Base-of-support, stride time variability, stride length variability, cadence, phase dispersions and gait symmetry indices were unaltered. The presence of measurable early gait abnormalities during the pre-plaque stages of AD in this relevant preclinical mouse model has direct translational relevance and supports the view that longitudinal monitoring of gait performance could be used in addition to behavioral testing to evaluate progression of the disease and to assess treatment efficacy.

Complications as a Mediator of the Perioperative Frailty-Mortality Association

BACKGROUND

Preoperative frailty is strongly associated with postoperative complications and mortality. However, the pathways between frailty, postoperative complications, and mortality are poorly described. The authors hypothesized that the occurrence of postoperative complications would mediate a substantial proportion of the total effect of frailty on mortality after elective noncardiac surgery.

METHODS

Following protocol registration, the authors conducted a retrospective cohort study of intermediate- to high-risk elective noncardiac surgery patients (2016) using National Surgical Quality Improvement Program data. The authors conducted Bayesian mediation analysis of the relationship between preoperative frailty (exposure, using the Risk Analysis Index), serious complications (mediator), and 30-day mortality (outcome), comprehensively adjusting for confounders. The authors estimated the total effect of frailty on mortality (composed of the indirect effect mediated by complications and the remaining direct effect of frailty) and estimated the proportion of the frailty-mortality association mediated by complications.

RESULTS

The authors identified 205,051 patients; 1,474 (0.7%) died. Complications occurred in 20,211 (9.9%). A 2 SD increase in frailty score resulted in a total association with mortality equal to an odds ratio of 3.79 (95% credible interval, 2.48 to 5.64), resulting from a direct association (odds ratio, 1.76; 95% credible interval, 1.34 to 2.30) and an indirect association mediated by complications (odds ratio, 2.15; 95% credible interval, 1.58 to 2.96). Complications mediated 57.3% (95% credible interval, 40.8 to 73.8) of the frailty-mortality association. Cardiopulmonary complications were the strongest mediators among complication subtypes.

CONCLUSIONS

Complications mediate more than half of the association between frailty and postoperative mortality in elective noncardiac surgery.

EDITOR’S PERSPECTIVE