Principles and Issues for Physical Frailty Measurement and Its Clinical Application

Unmet Questions About Frailty in Kidney Transplant Candidates

Frailty occurs frequently among patients with advanced chronic kidney disease, especially among women. Assessing frailty in kidney transplant (KT) candidates is crucial for informing them about associated risks. However, there is poor agreement between frailty scales and research on their correlation with transplant outcomes. Being prefrail significantly impacts both graft and patient survival, often beginning with just 1 Fried criterion. Rather than viewing frailty as a categorical state, it should be regarded as a spectrum ranging from 1 to 5 criteria, with the risk of adverse outcomes escalating as frailty worsens. Frailty status fluctuates during the waiting period for KT; hence, a 1-time frailty evaluation is insufficient to determine risks and implement strategies for improving functional status. Further research should investigate the components of frailty that most frequently change during this waiting period and establish strategies to prevent or reverse frailty. Although careful evaluation of frail KT candidates is necessary to prevent early complications and mortality, exclusion based solely on a frailty score is unwarranted. Instead, efforts should focus on timely interventions to enhance their condition before transplantation. Although evidence is limited, exercise programs appear feasible and yield positive results. A pretransplant clinical framework encompassing multimodal prehabilitation-comprising physical therapy, nutritional measures, and psychological support-during the waiting list period may help alleviate the effects of frailty and poor fitness after KT, ultimately improving key outcomes. Despite logistical challenges, there is a pressing need for interventional trials in this area.

Validation of the Self-Reported Edmonton Frail Scale - Acute Care in Patients ≥ 65 Years Undergoing Surgery

BACKGROUND

Frailty is common in geriatric emergency surgery and associated with increased risk for poor postoperative outcomes. Frailty screening is challenging in emergency settings. The Edmonton Frail Scale (EFS) is a valid tool to screen for patients at high risk for poor postoperative outcomes. Recently, the EFS was modified to decrease dependence on staff to perform physical measures. This modification, the EFS-Acute Care (EFS-AC), has not been validated. We wish to assess the agreement between the EFS and the EFS-AC.

STUDY DESIGN

We performed a prospective cohort study from 10/2021 - 10/2022 screening 688 patients ≥ 65 years with both the EFS and EFS-AC preoperatively. We assessed the ability of the EFS-AC to discriminate frailty identified by the EFS and compared the association of both scales with loss of independence (LOI), hospital length of stay (LOS), ICU admissions, and ICU LOS. Receiver Operator Curves were used to estimate the discriminatory thresholds for LOI.

RESULTS

688 patients with a median age 73 (IQR 68, 77) were enrolled. The EFS-AC was able to discriminate individuals' frailty status by the EFS with excellent agreement (AUC 0.971 [0.958, 0.983]). An EFS-AC threshold score of ≥ 6 points lead to 93.60% of individuals being correctly identified (77.87% sensitivity and 97.00% specificity). Both EFS and EFS-AC ≥ 6 were similarly associated with a higher risk for all clinical outcomes assessed and demonstrated similar ability to predict LOI.

CONCLUSIONS

The EFS-AC is a valid preoperative frailty screen, and due to its self-reported nature, can be administered in the acute care setting, during virtual visits, or through digital health apps. Real-time screening can assist with better understanding patient needs and lead to interventions to prevent poor hospital outcomes.

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.

Prevalence and feasibility of assessing the frailty phenotype among hemodialysis patients in a dialysis unit

BACKGROUND

Frailty increases risk of morbidity and mortality in hemodialysis patients. Frailty assessments could trigger risk reduction interventions if broadly adopted in clinical practice. We aimed to assess the clinical feasibility of frailty assessment among Veteran hemodialysis patients.

METHODS

Hemodialysis patients' ≥50 years were recruited from a single dialysis unit between 9/1/2021 and 3/31/2022.Patients who consented underwent a frailty phenotype assessment by clinical staff. Five criteria were assessed: unintentional weight loss, low grip strength, self-reported exhaustion, slow gait speed, and low physical activity. Participants were classified as frail (3-5 points), pre-frail (1-2 points) or non-frail (0 points). Feasibility was determined by the number of eligible participants completing the assessment.

RESULTS

Among 82 unique dialysis patients, 45 (52%) completed the assessment, 13 (16%) refused, 18 (23%) were not offered the assessment due to death, transfers, or switch to transplant or peritoneal dialysis, and 6 patients were excluded because they did not meet mobility criteria. Among assessed patients, 40(88%) patients were identified as pre-frail (46.6%) or frail (42.2%). Low grip strength was most common (90%). Those who refused were more likely to have peripheral vascular disease (p = 0.001), low albumin (p = 0.0187), low sodium (p = 0.0422), and ineligible for kidney transplant (p = 0.005).

CONCLUSIONS

Just over half of eligible hemodialysis patients completed the frailty assessment suggesting difficulty with broad clinical adoption expectations. Among those assessed, frailty and pre-frailty prevalence was high. Given patients who were not tested were clinically high risk, our reported prevalence likely underestimates true frailty prevalence. Providing frailty reduction interventions to all hemodialysis patients could have high impact for this group.

Higher baseline resting metabolic rate is associated with 1-year frailty decline among older adults residing in an urban area

BACKGROUND

Dysregulated energy metabolism is one hypothesized mechanism underlying frailty. Resting energy expenditure, as reflected by resting metabolic rate (RMR), makes up the largest component of total energy expenditure. Prior work relating RMR to frailty has largely been done in cross section with mixed results. We investigated whether and how RMR related to 1-year frailty change while adjusting for body composition.

METHODS

N = 116 urban, predominantly African-American older adults were recruited between 2011 and 2019. One-year frailty phenotype (0-5) was regressed on baseline RMR, frailty phenotype, demographics and body composition (DEXA) in an ordinal logistic regression model. Multimorbidity (Charlson comorbidity scale, polypharmacy) and cognitive function (Montreal Cognitive Assessment) were separately added to the model to assess for change to the RMR-frailty relationship. The model was then stratified by baseline frailty status (non-frail, pre-frail) to explore differential RMR effects across frailty.

RESULTS

Higher baseline RMR was associated with worse 1-year frailty (odds ratio = 1.006 for each kcal/day, p = 0.001) independent of baseline frailty, demographics, and body composition. Lower fat-free mass (odds ratio = 0.88 per kg mass, p = 0.008) was independently associated with worse 1-year frailty scores. Neither multimorbidity nor cognitive function altered these relationships. The associations between worse 1-year frailty and higher baseline RMR (odds ratio = 1.009, p < 0.001) and lower baseline fat-free mass (odds ratio = 0.81, p = 0.006) were strongest among those who were pre-frail at baseline.

DISCUSSION

We are among the first to relate RMR to 1-year change in frailty scores. Those with higher baseline RMR and lower fat-free mass had worse 1-year frailty scores, but these relationships were strongest among adults who were pre-frail at baseline. These relationships were not explained by chronic disease or impaired cognition. These results provide new evidence suggesting higher resting energy expenditure is associated with accelerate frailty decline.

A crosswalk of commonly used frailty scales

BACKGROUND

Several validated scales have been developed to measure frailty, yet the direct relationship between these measures and their scores remains unknown. To bridge this gap, we created a crosswalk of the most commonly used frailty scales.

METHODS

We used data from 7070 community-dwelling older adults who participated in National Health and Aging Trends Study (NHATS) Round 5 to construct a crosswalk among frailty scales. We operationalized the Study of Osteoporotic Fracture Index (SOF), FRAIL Scale, Frailty Phenotype, Clinical Frailty Scale (CFS), Vulnerable Elder Survey-13 (VES-13), Tilburg Frailty Indictor (TFI), Groningen Frailty Indicator (GFI), Edmonton Frailty Scale (EFS), and 40-item Frailty Index (FI). A crosswalk between FI and the frailty scales was created using the equipercentile linking method, a statistical procedure that produces equivalent scoring between scales according to percentile distributions. To demonstrate its validity, we determined the 4-year mortality risk across all scales for low-risk (equivalent to FI <0.20), moderate-risk (FI 0.20 to <0.40), and high-risk (FI ≥0.40) categories.

RESULTS

Using NHATS, the feasibility of calculating frailty scores was at least 90% for all nine scales, with the FI having the highest number of calculable scores. Participants considered frail on FI (cutpoint of 0.25) corresponded to the following scores on each frailty measure: SOF 1.3, FRAIL 1.7, Phenotype 1.7, CFS 5.3, VES-13 5.5, TFI 4.4, GFI 4.8, and EFS 5.8. Conversely, individuals considered frail according to the cutpoint of each frailty measure corresponded to the following FI scores: 0.37 for SOF, 0.40 for FRAIL, 0.42 for Phenotype, 0.21 for CFS, 0.16 for VES-13, 0.28 for TFI, 0.21 for GFI, and 0.37 for EFS. Across frailty scales, the 4-year mortality risks between the same categories were similar in magnitude.

CONCLUSION

Our results provide clinicians and researchers with a useful tool to directly compare and interpret frailty scores across scales.

Substitution of self-reported measures for objectively assessed grip strength and slow walk in the Physical Frailty Phenotype: ramifications for validity

BACKGROUND

Frailty assessment promises to identify older adults at risk for adverse consequences following stressors and target interventions to improve health outcomes. The Physical Frailty Phenotype (PFP) is a widely-studied, well validated assessment but incorporates performance-based slow walk and grip strength criteria that challenge its use in some clinical settings. Variants replacing performance-based elements with self-reported proxies have been proposed. Our study evaluated whether commonly available disability self-reports could be substituted for the performance-based criteria in the PFP while still identifying as "frail" the same subpopulations of individuals.

METHODS

Parallel analyses were conducted in 3393 female and 2495 male Cardiovascular Health Study, Round 2 participants assessed in 1989-90. Candidate self-reported proxies for the phenotype's "slowness" and "weakness" criteria were evaluated for comparable prevalence and agreement by mode of measurement. For best-performing candidates: Frailty status (3 + positive criteria out of 5) was compared for prevalence and agreement between the PFP and mostly self-reported versions. Personal characteristics were compared between those adjudicated as frail by (a) only a self-reported version; (b) only the PFP; (c) both, using bivariable analyses and multinomial logistic regression.

RESULTS

Self-reported difficulty walking ½ mile was selected as a proxy for the phenotype's slowness criterion. Two self-reported weakness proxies were examined: difficulty transferring from a bed or chair or gripping with hands, and difficulty as just defined or in lifting a 10-pound bag. Prevalences matched to within 4% between self-reported and performance-based criteria in the whole sample, but in all cases the self-reported prevalence for women exceeded that for men by 11% or more. Cross-modal agreement was moderate, with by-criterion and frailty-wide Kappa statistics of 0.55-0.60 in all cases. Frail subgroups (a), (b), (c) were independently discriminated (p < 0.05) by race, BMI, and depression in women; by age in men; and by self-reported health for both.

CONCLUSIONS

Commonly used self-reported disability items cannot be assumed to stand in for performance-based criteria in the PFP. We found subpopulations identified as frail by resultant phenotypes versus the original phenotype to systematically differ. Work to develop self-reported proxies that more closely replicate their objective phenotypic counterparts than standard disability self-reports is needed.

Frailty assessment as part of transplant listing: yes, no or maybe?

Frailty, characterized by a decreased physiological reserve and an increased vulnerability to stressors, is common among kidney transplant (KT) candidates and recipients. In this review, we present and summarize the key arguments for and against the assessment of frailty as part of KT evaluation. The key arguments for including frailty were: (i) sheer prevalence and far-reaching consequences of frailty on KT, and (ii) the ability to conduct a more holistic and objective evaluation of candidates, removing the inaccuracy associated with 'eye-ball' assessments of transplant fitness. The key argument against were: (i) lack of agreement on the definition of frailty and which tools should be used in renal populations, (ii) a lack of clarity on how, by whom and how often frailty assessments should be performed, and (iii) a poor understanding of how acute stressors affect frailty. However, it is the overwhelming opinion that the time has come for frailty assessments to be incorporated into KT listing. Although ongoing areas of uncertainty exist and further evidence development is needed, the well-established impact of frailty on clinical and experiential outcomes, the invaluable information obtained from frailty assessments, and the potential for intervention outweigh these limitations. Proactive and early identification of frailty allows for individualized and improved risk assessment, communication and optimization of candidates.

Development and validation of a physical frailty phenotype index-based model to estimate the frailty index

BACKGROUND

The conventional count-based physical frailty phenotype (PFP) dichotomizes its criterion predictors-an approach that creates information loss and depends on the availability of population-derived cut-points. This study proposes an alternative approach to computing the PFP by developing and validating a model that uses PFP components to predict the frailty index (FI) in community-dwelling older adults, without the need for predictor dichotomization.

METHODS

A sample of 998 community-dwelling older adults (mean [SD], 68 [7] years) participated in this prospective cohort study. Participants completed a multi-domain geriatric screen and a physical fitness assessment from which the count-based PFP and the 36-item FI were computed. One-year prospective falls and hospitalization rates were also measured. Bayesian beta regression analysis, allowing for nonlinear effects of the non-dichotomized PFP criterion predictors, was used to develop a model for FI ("model-based PFP"). Approximate leave-one-out (LOO) cross-validation was used to examine model overfitting.

RESULTS

The model-based PFP showed good calibration with the FI, and it had better out-of-sample predictive performance than the count-based PFP (LOO-R2, 0.35 vs 0.22). In clinical terms, the improvement in prediction (i) translated to improved classification agreement with the FI (Cohen's kw, 0.47 vs 0.36) and (ii) resulted primarily in a 23% (95%CI, 18-28%) net increase in FI-defined "prefrail/frail" participants correctly classified. The model-based PFP showed stronger prognostic performance for predicting falls and hospitalization than did the count-based PFP.

CONCLUSION

The developed model-based PFP predicted FI and clinical outcomes more strongly than did the count-based PFP in community-dwelling older adults. By not requiring predictor cut-points, the model-based PFP potentially facilitates usage and feasibility. Future validation studies should aim to obtain clear evidence on the benefits of this approach.

Trends in post-acute care and outcomes for Medicare beneficiaries hospitalized for heart failure between 2008 and 2015

BACKGROUND

Heart failure (HF) is the leading cause of hospitalization among older adults in the United States and results in high rates of post-acute care (PAC) utilization. Federal policies have focused on shifting PAC to less intensive settings and reducing length of stay to lower spending. This study evaluates the impact of policy changes on PAC use among Medicare beneficiaries hospitalized with HF between 2008 and 2015 by (1) characterizing trends in PAC use and cost and (2) evaluating changes in readmission, mortality, and days in the community, overall and by frailty.

METHODS

Annual cross-section prospective cohorts of all HF admissions between 1/1/2008 and 9/30/2015 among a 20% random sample of all Medicare Fee-for-Service beneficiaries (n = 718,737). The Claims-based Frailty Index (CFI) was used to classify frailty status. Multivariable regression models were used to evaluate trends in first discharge location, readmissions, mortality, days alive in the community, and costs; overall and by frailty status.

RESULTS

Frailty was prevalent among HF patients: 54.1% were prefrail, 37.0% mildly frail, and 6.9% moderate to severely frail. Between 2008 and 2015, almost 4% more HF beneficiaries received PAC, with most of the increase concentrated in skilled nursing facilities (SNF) (+2.3%) and home health agencies (HHA) (+1.1%), and PAC cost increased by $123 (3.5%). Over the 180-days follow-up after hospitalization, hospital readmissions decreased significantly (-3.4% at 30-day; -6.3% at 180-day), days alive in the community increased (+1.5), and 180-day Medicare costs declined $2948 (-18.7%) without negative impact in mortality (except a minor increase in the pre-frail group). Gains were greatest among the frailest patients.

CONCLUSIONS

Medicare beneficiaries hospitalized with HF spent more time in the community and experienced lower rehospitalization rates at lower cost without significant increases in mortality. However, important opportunities remain to optimize care for frail older adults hospitalized with HF.

Frailty: Pathophysiology, Theoretical and Operational Definition(s), Impact, Prevalence, Management and Prevention, in an Increasingly Economically Developed and Ageing World

The world's population is ageing, and most older adults experience a later life burdened with disease and disability. Frailty is a multidimensional and dynamic condition characterized by declines in reserve and function across multiple physiological systems, such that the ability to cope with every day or acute stressors becomes compromised. It is projected to become one of the most serious public health challenges economically developed societies will face in the coming century. This review provides a comprehensive overview of frailty, exploring its pathophysiology, theoretical and operational definition(s), impact, prevalence, management, and prevention, within the context of its emergence as a major public health challenge, in an increasingly economically developed and ageing world. Further, this review discusses the major limitations, deficiencies, and knowledge gaps presently within the field, and future research directions pertinent to the advancement of frailty research and the promotion of healthy longevity among the increasing global population of older adults.

Exploring Shared Effects of Multisensory Impairment, Physical Dysfunction, and Cognitive Impairment on Physical Activity: An Observational Study in a National Sample

Multisensory, physical, and cognitive dysfunction share age-related physiologic disturbances and may have common health effects. We determined whether the effect of multisensory impairment on physical activity (PA) is explained by physical (timed up and go) or cognitive (Short Portable Mental Status Questionnaire) dysfunction. A National Social Life, Health, and Aging Project participant subset (n = 507) underwent objective sensory testing in 2005-2006 and wrist accelerometry in 2010-2011. We related multisensory impairment to PA using multivariate mixed-effects linear regression and compared the effect magnitude after adjusting for physical then cognitive dysfunction. Worse multisensory impairment predicted lower PA across three scales (Global Sensory Impairment: β = -0.04, 95% confidence interval [-0.07, -0.02]; Total Sensory Burden: β = -0.01, 95% confidence interval [-0.03, -0.003]; and Number of Impaired Senses: β = -0.02, 95% confidence interval [-0.04, -0.004]). Effects were similar after accounting for physical and cognitive dysfunction. Findings suggest that sensory, physical, and cognitive dysfunction have unique mechanisms underlying their PA effects.

Screening accuracy of percentage predicted gait speed for prefrailty/frailty in community-dwelling older adults

AIM

In order to account for the variability in gait speed due to demographic factors, an observed gait speed value can be compared with its predicted value based on age, sex, and body height (observed gait speed divided by predicted gait speed, termed "GS%predicted" henceforth). This study aimed to examine the screening accuracy of an optimal GS%predicted threshold for prefrailty/frailty.

METHODS

This cross-sectional study included 998 community-dwelling ambulant participants aged >50 years (mean age = 68 years). Participants completed a multi-domain geriatric screen and a physical fitness assessment, from which the 10-m habitual gait speed, GS%predicted, Physical Frailty Phenotype (PFP) index, and 36-item Frailty Index (FI) were computed.

RESULTS

Based on the FI, ~49% of participants had pre-frailty or frailty. The optimal threshold of GS%predicted (0.93) had greater screening accuracy than the 1.0 m/s fixed threshold for gait speed (AUC, 0.65 vs. 0.60; DeLong's P < 0.001). Replacing gait speed with GS%predicted in the PFP improved its overall discrimination (AUC, 0.70 vs. 0.67 of original PFP; DeLong's P < 0.001).

CONCLUSIONS

Defining a "slow" gait speed by a GS%predicted value of <0.93 provided greater screening accuracy than the traditional 1.0 m/s threshold for gait speed. Our results also support the use of GS%predicted-derived PFP to identify older adults at risk of prefrailty/frailty. Geriatr Gerontol Int 2022; ••: ••-••.

Impact of physical and functional fitness on mortality from all causes of physically independent older adults

OBJECTIVE

To provide reference values for functional fitness tests (PFFT) and verify the capability of these tests alone and grouped into a general index (GFFI-6), to predict mortality from all causes, during seven years of follow-up of physically independent older adults.

METHODS

The sample consisted of 422 older adults, evaluated at baseline using six PFFTs, as well as sociodemographic, behavioral, anthropometric, and comorbidity variables. Mortality from all causes was followed for seven subsequent years. The sample was subdivided into four groups according to sex and age. Performances in the PFFT and GFFI-6 tests were ranked into "low", "regular", and "high".

RESULTS

Cox proportional regression, with the adjustment of variables, indicated that the Unipedal Balance Test (BAL), Body Agility (AGI), Sit and Stand-up (SIT-SD) tests, and GFFI-6 were able to significantly predict mortality, indicating that older adults with "low" performance have, respectively, a 2.7 (CI=1.54-4.89, p = 0.01), 4.2 (CI=2.10-8.41), 2.5 (CI=1.44-4.65, p = 0.01), and 4.7 (CI=2.10-10.81, p<0.01) times higher risk of death, compared to older adults with "high" performance.

CONCLUSION

BAL, AGI, and SIT-SD tests alone and tests grouped in the GFFI-6 were strong predictors of all-cause mortality in physically independent older adults.

Frailty-a risk factor of global and domain-specific cognitive decline among a nationally representative sample of community-dwelling older adult U.S. Medicare beneficiaries

OBJECTIVES

frail older adults may be more vulnerable to stressors, resulting in steeper declines in cognitive function. Whether the frailty-cognition link differs by cognitive domain remains unclear; however, it could lend insight into underlying mechanisms.

METHODS

we tested whether domain-specific cognitive trajectories (clock-drawing test, (CDT), immediate and delayed recall, orientation to date, time, president and vice-president naming) measured annually (2011-2016) differ by baseline frailty (physical frailty phenotype) in the National Health and Aging Trends Study (n = 7,439), a nationally representative sample of older adult U.S. Medicare beneficiaries, using mixed effects models to describe repeated measures of each cognitive outcome. To determine if the association between frailty and subsequent cognitive change differed by education, we tested for interaction using the Wald test.

RESULTS

we observed steeper declines for frail compared to non-frail participants in each domain-specific outcome, except for immediate recall. Largest differences in slope were observed for CDT (difference = -0.12 (standard deviations) SD/year, 95%CI: -0.15, -0.08). By 2016, mean CDT scores for frail participants were 1.8 SD below the mean (95%CI: -1.99, -1.67); for non-frail participants, scores were 0.8 SD below the mean (95%CI: -0.89, -0.69). Associations differed by education for global cognitive function (Pinteraction < 0.001) and for each domain-specific outcome: CDT (Pinteraction < 0.001), orientation (Pinteraction < 0.001), immediate (Pinteraction < 0.001) and delayed (Pinteraction < 0.001) word recalls.

CONCLUSION

frailty is associated with lower levels and steeper declines in cognitive function, with strongest associations for executive function. These findings suggest that aetiologies are multifactorial, though primarily vascular related; further research into its association with dementia sub-types and related pathologies is critical.

Development and Validation of an Inflammatory-Frailty Index for Kidney Transplantation

BACKGROUND

Physical frailty phenotype is characterized by decreased physiologic reserve to stressors and associated with poor outcomes, such as delirium and mortality, that may result from post-kidney transplant (KT) inflammation. Despite a hypothesized underlying pro-inflammatory state, conventional measures of frailty typically do not incorporate inflammatory biomarkers directly. Among KT candidates and recipients, we evaluated the inclusion of inflammatory biomarkers with traditional physical frailty phenotype components.

METHODS

Among 1154 KT candidates and recipients with measures of physical frailty phenotype and inflammation (interleukin 6 [IL6], tumor necrosis factor alpha [TNFα], C-reactive protein [CRP]) at 2 transplant centers (2009-2017), we evaluated construct validity of inflammatory-frailty using latent class analysis. Inflammatory-frailty measures combined 5 physical frailty phenotype components plus the addition of an individual inflammatory biomarkers, separately (highest tertiles) as a sixth component. We then used Kaplan-Meier methods and adjusted Cox proportional hazards to assess post-KT mortality risk by inflammatory-frailty (n = 378); Harrell's C-statistics assessed risk prediction (discrimination).

RESULTS

Based on fit criteria, a 2-class solution (frail vs nonfrail) for inflammatory-frailty was the best-fitting model. Five-year survival (frail vs nonfrail) was: 81% versus 93% (IL6-frailty), 87% versus 89% (CRP-frailty), and 83% versus 91% (TNFα-frailty). Mortality was 2.07-fold higher for IL6-frail recipients (95% CI: 1.03-4.19, p = .04); there were no associations between the mortality and the other inflammatory-frailty indices (TNFα-frail: 1.88, 95% CI: 0.95-3.74, p = .07; CRP-frail: 1.02, 95% CI: 0.52-2.03, p = .95). However, none of the frailty-inflammatory indices (all C-statistics = 0.71) improved post-KT mortality risk prediction over the physical frailty phenotype (C-statistics = 0.70).

CONCLUSIONS

Measurement of IL6-frailty at transplantation can inform which patients should be targeted for pre-KT interventions. However, the traditional physical frailty phenotype is sufficient for post-KT mortality risk prediction.

Nutrition and Frailty: Opportunities for Prevention and Treatment

Frailty is a syndrome of growing importance given the global ageing population. While frailty is a multifactorial process, poor nutritional status is considered a key contributor to its pathophysiology. As nutrition is a modifiable risk factor for frailty, strategies to prevent and treat frailty should consider dietary change. Observational evidence linking nutrition with frailty appears most robust for dietary quality: for example, dietary patterns such as the Mediterranean diet appear to be protective. In addition, research on specific foods, such as a higher consumption of fruit and vegetables and lower consumption of ultra-processed foods are consistent, with healthier profiles linked to lower frailty risk. Few dietary intervention studies have been conducted to date, although a growing number of trials that combine supplementation with exercise training suggest a multi-domain approach may be more effective. This review is based on an interdisciplinary workshop, held in November 2020, and synthesises current understanding of dietary influences on frailty, focusing on opportunities for prevention and treatment. Longer term prospective studies and well-designed trials are needed to determine the causal effects of nutrition on frailty risk and progression and how dietary change can be used to prevent and/or treat frailty in the future.

Frailty assessment of older adults, first-time applicants of public home care service in Norway

OBJECTIVE

Early detection of frailty is essential to prevent or delay disability. The most appropriate screening tool for frailty among home-dwelling older adults is under debate. The present study estimates the prevalence of frailty among older adults, first-time applicants of public home care service in Norway, and investigates the appropriateness of gait speed and Short Physical Performance Battery as screening-tools for frailty.

DESIGN AND SETTING

We conducted a cross-sectional study of 116 older adults >65 years applying for public home care service for the first time. Frailty was assessed by an adapted version of the Fried Frailty Phenotype. The test accuracies of gait speed and Short Physical Performance Battery to detect frailty were calculated for a general population >70 years in Norway.

RESULTS

62.1% of the participants were frail, 29.3% were prefrail, and 8.6% were robust. Mean gait speed and Short Physical Performance Battery-scores were significantly lower in frail compared to prefrail individuals, and significantly lower in prefrail compared to robust individuals. The sensitivity and specificity of gait speed at a cut point of 0.8 m/s to detect physical frailty phenotype was 99% and 68%, respectively.

CONCLUSIONS

The high prevalence of frailty in the present study indicates that screening for frailty should be considered at an earlier time point than when older adults apply for public home care service for the first time. Gait speed may be an appropriate screening tool for frailty in a general population >70 years in Norway.KEY POINTSThe prevalence of frailty among older adults, first-time applicants of public home care services in Norway is major.Screening for frailty should be considered before older adults apply for public home care service for the first time.Gait speed at a cut point at 0.8 m/s may be an appropriate screening tool for frailty in a general population >70 years in Norway.

The physical frailty syndrome as a transition from homeostatic symphony to cacophony

Frailty in aging marks a state of decreased reserves resulting in increased vulnerability to adverse outcomes when exposed to stressors. This Perspective synthesizes the evidence on the aging-related pathophysiology underpinning the clinical presentation of physical frailty as a phenotype of a clinical syndrome that is distinct from the cumulative-deficit-based frailty index. We focus on integrating the converging evidence on the conceptualization of physical frailty as a state, largely independent of chronic diseases, that emerges when the dysregulation of multiple interconnected physiological and biological systems crosses a threshold to critical dysfunction, severely compromising homeostasis. Our exegesis posits that the physiology underlying frailty is a critically dysregulated complex dynamical system. This conceptual framework implies that interventions such as physical activity that have multisystem effects are more promising to remedy frailty than interventions targeted at replenishing single systems. We then consider how this framework can drive future research to further understanding, prevention and treatment of frailty, which will likely preserve health and resilience in aging populations.

The Sequence of Physical and Cognitive Impairment and the Association with Mortality Among Unimpaired Older Mexican Adults

BACKGROUND

Many older adults become physically and cognitively impaired. However, it is unclear whether unimpaired older adults are more likely to become physically or cognitively impaired first and if this sequence impacts mortality risk.

METHODS

Data came from the Mexican Health and Aging Study. The sample included 1,283 participants aged ≥60 years who were physically and cognitively unimpaired in 2001. Multinomial logistic regression was used to estimate probabilities of being unimpaired, cognitively impaired only, physically impaired only, or cognitively-physically impaired in 2003. Proportional hazard models were used to estimate mortality risk through 2015 according to physical and cognitive status in 2003.

RESULTS

The probabilities for being unimpaired, physically impaired only, cognitively impaired only, and cognitively-physically impaired in 2003 were 0.45, 0.22, 0.19, and 0.13, respectively. Older age, female sex, and arthritis were associated with significantly greater probability of becoming physically impaired only than cognitively impaired only in 2003. Cognitive impairment only (hazard ratio [HR] = 1.42, 95% confidence interval [CI] = 1.09-1.85) in 2003 but not physical impairment only (HR = 1.22, 95% CI = 0.94-1.58) was associated with greater mortality than being unimpaired in 2003. Cognitively-physically impaired participants had higher mortality risk than participants who were physically (HR = 1.58, 95% CI = 1.18-2.12) or cognitively (HR = 1.36, 95% CI = 1.01-1.84) impaired only.

DISCUSSION

The likelihood of becoming only physically or cognitively impaired over 2 years varies by demographic and health characteristics. The mortality risk for unimpaired older adults who become cognitively impaired only is similar to those who become physically impaired only. Research should determine if the sequence of cognitive and physical impairments is associated with other outcomes.