Frailty Syndrome in Geriatric Medicine

Frailty prevalence and efficient screening in primary care-based memory clinics

BACKGROUND

Little is known about the prevalence of frailty among patients with memory concerns attending a primary care-based memory clinic.

OBJECTIVE

This study aims to describe the prevalence of frailty among patients attending a primary care-based memory clinic and to determine if prevalence rates differ based on the screening tool that is used.

METHODS

We conducted a retrospective medical record review for all consecutive patients assessed in a primary care-based memory clinic over 8 months. Frailty was measured in 258 patients using the Fried frailty criteria, which relies on physical measures, and the Clinical Frailty Scale (CFS), which relies on functional status. Weighted kappa statistics were calculated to compare the Fried frailty and the CFS.

RESULTS

The prevalence of frailty was 16% by Fried criteria and 48% by the CFS. Agreement between Fried frailty and CFS was fair for CFS 5+ (kappa = 0.22; 95% confidence interval: 0.13, 0.32) and moderate for CFS 6+ (kappa = 0.47; 0.34, 0.61). Dual-trait measures of hand grip strength with gait speed were found to be a valid proxy for Fried frailty phenotype.

CONCLUSIONS

Among primary care patients with memory concerns, frailty prevalence rates differed based on the measure used. Screening for frailty in this population using measures relying on physical performance may be a more efficient approach for persons already at risk of further health instability from cognitive impairment. Our findings demonstrate how measure selection should be based on the objectives and context in which frailty screening occurs.

The role of frailty on quality of life in older adults during the COVID-19 pandemic

AIM

The impact of frailty, a physiological state characterized by reduced reserve for stressors and related to worse outcomes, on older adults during the pandemic is unclear. Our aim was to identify the effects of frailty among older adults during the COVID-19 pandemic.

METHODS

A total of 197 older adults who were not exposed to COVID-19 were assessed with an online survey one year after the pandemic began in Turkey. Frailty, quality of life, and fear of COVID-19 were assessed with the Tilburg Frailty Indicator, the Nottingham Health Profile, and the Fear of COVID-19 Scale, respectively. Since March 2020, changes in pain severity and localization, fatigue, and fear of falling were assessed. Multiple linear regression analyses were conducted.

RESULTS

In this study, 62.5% of the participants were frail. The prevalence of pain was significantly increased during the COVID-19 pandemic, but only among the frail. The increases in pain severity, fear of falling, and fatigue were significantly higher for the frail than the non-frail. The model including physical and psychological components of frailty and pain severity explained 49% of the variation in quality of life (R = 0.696; R² = 0.485; p < 0.001). The physical component of frailty had the highest impact on quality of life (B = 20.591; β = 0.334).

CONCLUSION

This study focused on negative outcomes that were experienced more by frail older adults compared to non-frail older adults when they were locked down at home for an extended period of time during the COVID-19 pandemic. It is necessary to quickly improve and maintain the health of these affected individuals.

Dysphagia is closely related to frailty in mild-to-moderate Alzheimer's disease

INTRODUCTION

Physical phenotype and the cumulative deficit model are two well-known concepts of frailty. One of the main components of frailty is loss of muscle mass and function, which may also include swallowing muscles, therefore is a risk factor for dysphagia. Since dysphagia is seen starting from the early stages of Alzheimer's Disease (AD), in this study we aimed to reveal the relationship between frailty and dysphagia and dysphagia-related quality of life through Swallow Quality of Life (SwalQoL) tool in patients with AD and compare them with cognitively intact older adults.

METHODS

Comprehensive geriatric assessment, dysphagia evaluation by Eating-Assessment Tool (EAT-10) and SwalQoL questionnaire, and frailty assessment via FRAIL and Clinical Frailty Scale (CFS) were performed on all 101 participants of the study. Thirty-five patients were cognitively intact, 36 patients were diagnosed with mild AD, and 30 patients were diagnosed with moderate AD.

RESULTS

Sex distribution was similar between the groups, however, there was a statistically significant age difference. The prevalence of frailty increased according to both frailty indexes as the cognitive status deteriorated. All parameters of SwalQoL except fear and sleep parameters deteriorated as cognitive status impaired. In quantile regression of the total score of the SwalQoL questionnaire and multivariable logistic regression of EAT-10, frailty, as defined by CFS and FRAIL, was associated with dysphagia and poor quality of life regardless of age, presence of dementia, as well as nutritional status.

CONCLUSION

Swallowing difficulties in AD negatively affects the quality of life, and it is closely related to frailty in mild-to-moderate AD.

Exploring Early Detection of Frailty Syndrome in Older Adults: Evaluation of Oxi-Immune Markers, Clinical Parameters and Modifiable Risk Factors

Ageing is accompanied with a decline in several physiological systems. Frailty is an age-related syndrome correlated to the loss of homeostasis and increased vulnerability to stressors, which is associated with increase in the risk of disability, comorbidity, hospitalisation, and death in older adults. The aim of this study was to understand the relationship between frailty syndrome, immune activation, and oxidative stress. Serum concentrations of vitamins A and E were also evaluated, as well as inflammatory biomarkers (CRP and IL-6) and oxidative DNA levels. A group of Portuguese older adults (≥65 years old) was engaged in this study and classified according to Fried’s frailty phenotype. Significant increases in the inflammatory mediators (CRP and IL-6), neopterin levels, kynurenine to tryptophan ratio (Kyn/Trp), and phenylalanine to tyrosine ratio (Phe/Tyr), and significant decreases in Trp and Tyr concentrations were observed in the presence of frailty. IL-6, neopterin, and Kyn/Trp showed potential as predictable biomarkers of frailty syndrome. Several clinical parameters such as nutrition, dependency scales, and polypharmacy were related to frailty and, consequently, may influence the associations observed. Results obtained show a progressive immune activation and production of pro-inflammatory molecules in the presence of frailty, agreeing with the inflammageing model. Future research should include different dimensions of frailty, including psychological, social, biological, and environmental factors.

Review of frailty measurement of older people: Evaluation of the conceptualization, included domains, psychometric properties, and applicability

The purposes of this review are to describe the existing research on frailty measurement of older people and to understand their characteristics, with a focus on conceptual definitions, psychometric properties, and diagnostic accuracies. We reviewed the published literature to explore if cross-cultural studies of different types of frailty measurements have been conducted and to determine their applicability in the community setting. Narrative review with limited electronic database search and cross reference searching of included studies was performed. Studies published after year 2001 were searched for using MEDLINE and CINAHL Plus databases with keywords. A total of 5144 search results were obtained, but only 42 frailty measurements were identified in 68 studies. For the type, three different measurements were indicated, namely, self-report instrument (n = 17), clinical observation assessment (n = 19), and mixed frailty assessment instrument (n = 6). Only 12 (29%) measurements examined reliability and validity. Nevertheless, over 35% did not perform any psychometric testing before applying. For diagnosis accuracies, 35 (83%) frailty measurements reported the cut-off value(s) for determining level of the frailty. However, the sensitivity (56%-89.5%) and specificity (52%-91.3%) varied. The applicability was also diverse and some frailty instruments should be only used in some specific population and mode of administration. This review provides an overview of three major types of frailty measurements used in different settings with different purposes. For estimating the prevalence of frailty of older people in a community, the self-report type may be appropriate. The psychometric properties of many reviewed instruments are reported insufficiently. The cut-off value(s) are usually suggested with diverse sensitivity and specificity. Self-report instruments, such as Groningen Frailty Indicator (GFI) and Tilburg Frailty Indicator (TFI), are the most extensively examined in terms of satisfactory psychometric properties. Thus, GFI and TFI, with the current evidence, are recommended to be used in the community setting for frailty screening tools.

Centenarians as models of healthy aging: Example of REST

Centenarians are a group of individuals exhibiting extreme longevity, who are characterized by a remarkable compression of morbidity. Therefore, centenarians have been postulated as a model of healthy aging. Different approaches have been used to decipher the biology and genetics of centenarians in order to identify key anti-aging pathways. The majority of studies have taken advantage of blood samples to perform their analysis. Besides, a recent study in human brain samples deciphered the transcription factor REST (Repressor Element-1 Silencing Transcription Factor) as an important player of extreme longevity and cognitive activity. This study goes from human to animal models and revealed that REST acts as an epigenetic regulator of neuronal homeostasis, to control aging and longevity. The aim of this view point is to summarize recent literature describing genetic and epigenetic factors, as well as molecular pathways associated with centenarians and the biology of aging. We will pay particular attention to the impact of REST in centenarians and longevity.

Age, sex and BMI influence on copper, zinc and their major serum carrier proteins in a large European population including Nonagenarian Offspring from MARK-AGE study

The analysis of copper (Cu) and zinc (Zn) along with their major serum carriers, albumin (Alb) and ceruloplasmin (Cp), could provide information on the capacity of humans to maintain homeostasis of metals (metallostasis). However, their relationship with aging, sex, BMI, as well as with nutritional and inflammatory markers was never investigated in a large-scale study. Here, we report results from the European large-scale cross-sectional study MARK-AGE in which Cu, Zn, Alb, Cp as well as nutritional and inflammatory parameters were determined in 2424 age-stratified subjects (35-75 years) including the general population (RASIG), nonagenarian offspring (GO), a well-studied genetic model of longevity, and spouses of GO (SGO). In RASIG, Cu to Zn ratio and Cp to Alb ratio were higher in women than in men. Both ratios increased with aging because Cu and Cp increased and Alb and Zn decreased. Cu, Zn, Alb and Cp were found associated with several inflammatory as well as nutritional biomarkers.GO showed higher Zn levels and higher Zn to Alb ratio compared to RASIG, but we did not observe significant differences with SGO, likely as a consequence of the low sample size of SGO and the shared environment. Our results show that aging, sex, BMI and GO status are characterized by different levels of Cu, Zn and their serum carrier proteins. These data and their relationship with inflammatory biomarkers support the concept that loss of metallostasis is a characteristic of inflammaging.

Age as a Predictor for Complications and Patient-reported Outcomes in Multilevel Transforaminal Lumbar Interbody Fusions: Analyses From the Michigan Spine Surgery Improvement Collaborative (MSSIC)

STUDY DESIGN

Retrospective review of a multi-institutional data registry.

OBJECTIVE

The authors sought to determine the association between age and complications & patient-reported outcomes (PRO) in patients undergoing multilevel transforaminal interbody lumbar fusion (MTLIF).

SUMMARY OF BACKGROUND DATA

Elderly patients undergoing MTLIF are considered high risk. However, data on complications and PRO are lacking. Additionally, safety of multilevel lumbar fusion in the elderly remains uncertain.

METHODS

Patients ≥50-year-old who underwent MTLIF for degenerative lumbar spine conditions were analyzed. Ninety-day complications and PROs (baseline, 90-d, 1-y, 2-y) were queried using the MSSIC database. PROs were measured by back & leg visual analog scale (VAS), Patient-reported Outcomes Measurement Information System (PROMIS), EuroQol-5D (EQ-5D), and North American Spine Society (NASS) Patient Satisfaction Index. Univariate analyses were used to compare among elderly and complication cohorts. Generalized estimating equation (GEE) was used to identify predictors of complications and PROs.

RESULTS

A total of 3120 patients analyzed with 961 (31%) ≥ 70-y-o and 2159 (69%) between 50-69. A higher proportion of elderly experienced postoperative complications (P = .003) including urinary retention (P = <.001) and urinary tract infection (P = .002). Multivariate analysis demonstrated that age was not independently associated with complications. Number of operative levels was associated with any (P = .001) and minor (P = .002) complication. Incurring a complication was independently associated with worse leg VAS and PROMIS scores (P = <.001). Preoperative independent ambulation was independently associated with improved PROMIS, and EQ5D (P = <.001). Within the elderly, preoperative independent ambulation and lower BMI were associated with improved PROMIS (P = <.001). Complications had no significant effect on PROs in the elderly.

CONCLUSIONS

Age was not associated with complications nor predictive of functional outcomes in patients who underwent MTLIF. Age alone, therefore, may not be an appropriate surrogate for risk. Furthermore, baseline preoperative independent ambulation was associated with better clinical outcomes and should be considered during preoperative surgical counseling.Level of Evidence: 3.

Sarcopenia as a Prognostic Factor for 90-Day and Overall Mortality in Patients Undergoing Spine Surgery for Metastatic Tumors: A Multicenter Retrospective Cohort Study

BACKGROUND

Novel methods in predicting survival in patients with spinal metastases may help guide clinical decision-making and stratify treatments regarding surgery vs palliative care.

OBJECTIVE

To evaluate whether the frailty/sarcopenia paradigm is predictive of survival and morbidity in patients undergoing surgery for spinal metastasis.

METHODS

A total of 271 patients from 4 tertiary care centers who had undergone surgery for spinal metastasis were identified. Frailty/sarcopenia was defined by psoas muscle size. Survival hazard ratios were calculated using multivariate analysis, with variables from demographic, functional, oncological, and surgical factors. Secondary outcomes included improvement of neurological function and postoperative morbidity.

RESULTS

Patients in the smallest psoas tertile had shorter overall survival compared to the middle and largest tertile. Psoas size (PS) predicted overall mortality more strongly than Tokuhashi score, Tomita score, and Karnofsky Performance Status (KPS). PS predicted 90-d mortality more strongly than Tokuhashi score, Tomita score, and KPS. Patients with a larger PS were more likely to have an improvement in deficit compared to the middle tertile. PS was not predictive of 30-d morbidity.

CONCLUSION

In patients undergoing surgery for spine metastases, PS as a surrogate for frailty/sarcopenia predicts 90-d and overall mortality, independent of demographic, functional, oncological, and surgical characteristics. The frailty/sarcopenia paradigm is a stronger predictor of survival at these time points than other standards. PS can be used in clinical decision-making to select which patients with metastatic spine tumors are appropriate surgical candidates.

Frailty syndrome, biomarkers and environmental factors - A pilot study

Frailty is an age-related syndrome expected to increase over the next decades. This syndrome has been identified to be the most common condition leading to disability, institutionalisation and death in the elderly. The aim of this pilot study is to investigate a possible link between frailty status, biomarkers and environmental exposures. A group of 71 older adults (≥65 years old) was engaged in this study. The study population was classified as 45.1% robust, 45.1% pre-frail and 9.8% frail. A significant higher prevalence of second-hand smokers was found in the pre-frail group when compared to robust. Furthermore, a higher prevalence of robust individuals was found among those consuming home-produced vegetables and water from well/springs. Significant differences were found between data collected in a lifetime exposure questionnaire (LTEQ) and the levels of genotoxicity endpoints and the mercury levels analysed regarding some exposure-related parameters, namely, smoking habits, intake of home-produced vegetables and the use of pesticides in agriculture. Understanding if the way we live(d) or worked can impact the way we age are important questions to be explored. Data obtained in this pilot study encourage further studies on this matter, exploring the role of exposures history and its impact on health.

The emerging role of sarcopenia as a prognostic indicator in patients undergoing abdominal wall hernia repairs: a systematic review of the literature

BACKGROUND

There is strong evidence suggesting that excessive fat distribution, for example, in the bowel mesentery or a reduction in lean body mass (sarcopenia) can influence short-, mid-, and long-term outcomes from patients undergoing various types of surgery. Body composition (BC) analysis aims to measure and quantify this into a parameter that can be used to assess patients being treated for abdominal wall hernia (AWH). This study aims to review the evidence linking quantification of BC with short- and long-term abdominal wall hernia repair outcomes.

METHODS

A systematic review was performed according to the PRISMA guidelines. The literature search was performed on all studies that included BC analysis in patients undergoing treatment for AWH using Medline, Google Scholar and Cochrane databases by two independent reviewers. Outcomes of interest included short-term recovery, recurrence outcomes, and long-term data.

RESULTS

201 studies were identified, of which 4 met the inclusion criteria. None of the studies were randomized controlled trials and all were cohort studies. There was considerable variability in the landmark axial levels and skeletal muscle(s) chosen for analysis, alongside the methods of measuring the cross-sectional area and the parameters used to define sarcopenia. Only two studies identified an increased risk of postoperative complications associated with the presence of sarcopenia. This included an increased risk of hernia recurrence, postoperative ileus and prolonged hospitalisation.

CONCLUSION

There is some evidence to suggest that BC techniques could be used to help predict surgical outcomes and allow early optimisation in AWH patients. However, the lack of consistency in chosen methodology, combined with the outdated definitions of sarcopenia, makes drawing any conclusions difficult. Whether body composition modification can be used to improve outcomes remains to be determined.

Interventions aimed at loneliness and fall prevention reduce frailty in elderly urban population

Frailty is a pronounced symptom of aging associated with multiple comorbid states and adverse outcomes. The aim of this study was to evaluate the impact of 2 interventions, one based on prevention of falls and the other on prevention of loneliness, on total frailty and dimensions of frailty in urban community-dwelling elderly as well as associations with independent living.This prospective interventional study followed up 410 persons aged 75 to 95. The participants of the control and intervention groups were monitored through a public health intervention programme. The level of frailty was measured by the Tilburg Frailty Indicator (TFI) questionnaire and the factors of independent living were analyzed using validated questionnaires.After 1 year, physical frailty measured in the control group showed a statistically significant increase (r = -0.11), while in the intervention groups physical frailty did not increase (both P > .05). Psychological frailty measured after 1 year in the control group was significantly higher (r = -0.19), as well as in the group where the public health interventions to reduce loneliness were carried out (r = -0.19). Psychological frailty did not increase in the group in which public health interventions to prevent falls were carried out, and social frailty did not increase at all in the study period. The total level of frailty in the control group after 1 year was significantly increased (r = -0.19), while no increase was seen in the overall frailty in the intervention group. Multivariate analysis has shown that both interventions where independently associated with lower end frailty. Additionally, higher baseline frailty and visit to a physician in the last year were positively associated with higher end-study frailty level, while higher number of subjects in the household and higher total psychological quality of life (SF-12) were independently associated with lower end-study frailty. Only in the prevention of falls group there was no increase in restriction in the activities of daily living throughout study follow-up.Public health interventions to prevent falls and to prevent loneliness have a positive effect on the frailty and independent living of the elderly living in their own homes in an urban community.

Sarcopenia Predicts Overall Survival in Patients with Lung, Breast, Prostate, or Myeloma Spine Metastases Undergoing Stereotactic Body Radiation Therapy (SBRT), Independent of Histology

BACKGROUND

Predicting survival of patients with spinal metastases would help stratify treatments from aggressive to palliation.

OBJECTIVE

To evaluate whether sarcopenia predicts survival in patients with lung, breast, prostate, or multiple myeloma spinal metastases.

METHODS

Psoas muscle measurements in patients with spinal metastasis were taken from computed tomography scans at 2 time points: at first episode of stereotactic body radiation therapy (SBRT) and from the most recent scan available. Overall survival and hazard ratios were calculated with multivariate cox proportional hazards regression analyses.

RESULTS

In 417 patients with spinal metastases, 40% had lung cancer, 27% breast, 21% prostate, and 11% myeloma. Overall survival was not associated with age, sex, ethnicity, levels treated, or SBRT volume. Multivariate analysis showed patients in the lowest psoas tertile had shorter survival (222 d, 95% CI = 185-323 d) as compared to the largest tertile (579 d, 95% CI = 405-815 d), (HR1.54, P = .005). Median psoas size as a cutoff value was also strongly predictive for survival (HR1.48, P = .002). Survival was independent of tumor histology. The psoas/vertebral body ratio was also successful in predicting overall survival independent of tumor histology and gender (HR1.52, P &lt; .01). Kaplan–Meier survival curves visually represent survival (P = .0005).

CONCLUSION

In patients with spine metastases, psoas muscle size as a hallmark of frailty/sarcopenia is an objective, simple, and effective way to identify patients who are at risk for shorter survival, regardless of tumor histology. This information can be used to help with surgical decision making in patients with advanced cancer, as patients with small psoas sizes are at higher risk of death.

The Association Between Race and Frailty in Older Adults Presenting to a Nononcologic Urology Practice

OBJECTIVE

To explore whether there is an association between nonwhite race and frailty among older adults presenting to an academic nononcologic urology practice.

MATERIALS AND METHODS

This is a prospective study of individuals ages ≥65years presenting to a nononcologic urology practice between December 2015 and November 2016. All individuals had a Timed Up and Go Test (TUGT, where a slower TUGT time of ≥15 seconds is suggestive of frailty. TUGT times, race (white vs nonwhite), and other clinical data were extracted from the electronic medical record using direct queries. Multivariable logistic regression was used to identify the association between race and slower TUGT times while adjusting for age, gender, number of medications, body mass index, and number of urologic diagnoses.

RESULTS

Among the 1715 individuals in our cohort, 33.9% were of nonwhite race and 15.3% had TUGT ≥15 seconds. A higher percentage of nonwhite individuals had TUGT times ≥15 seconds compared to white individuals (23.6% vs 11.1%, P <.01). TUGT times ≥15 seconds were significantly associated with nonwhite race after adjusting for clinical factors (adjusted odds ratio 2.5, 95% confidence interval 1.8-3.3).

CONCLUSION

Among older adults presenting to an academic nononcologic urology practice, nonwhite race was associated with increased odds of frailty. A greater understanding of the relationship between race and frailty is needed to better address the needs of this vulnerable population.

Association of albumin and cholesterol levels with incidence of hypoglycaemia in people admitted to general internal medicine units

AIM

To study the association between serum albumin and cholesterol levels at hospital admission and incident hypoglycaemia among people admitted to internal medicine units.

METHODS

In this cross-sectional analysis, we examined the electronic medical records of people hospitalized in internal medicine departments. Data extracted included all glucose measurements as well as serum albumin and cholesterol, which were measured upon admission. A hypoglycaemia event was recorded for a given person if at least one glucose measurement of ≤ 3.9 mmol/l was recorded during the hospital stay. Regression analysis was used to determine which clinical measures predict hypoglycaemia.

RESULTS

During the acquisition period, 45 224 people (mean age 68.9 ± 17.8 years, 49.4% male, 21.1% diabetes mellitus) were discharged from internal medicine units. Hypoglycaemia was documented in 7.5% of these individuals (15.4% of people with diabetes vs. 5.5% of those without; P < 0.001). Logistic regression showed that both serum albumin [odds ratio (OR) 0.908, 95% confidence interval (CI) 0.896-0.919; P < 0.001) and cholesterol (OR 0.938, 95% CI 0.896-0.981; P = 0.005] were significantly associated with incident hypoglycaemia. Results remained significant even after controlling for age, sex, average glucose during hospitalization, length of hospital stay, acute infection upon admission, diabetes status, haemoglobin, white blood cell count and C-reactive levels. A combination of hypoalbuminaemia (< 35 g/l) and hypocholesterolaemia (< 3.37 mmol/l) upon admission greatly increased the risk of incident hypoglycaemia (OR 2.544, 95% CI 2.096-3.088; P < 0.001).

CONCLUSION

Hypoalbuminaemia and hypocholesterolaemia predict incident hypoglycaemia in the hospital setting among people with and without diabetes mellitus.

Application of morphometrics as a predictor for survival in female patients with breast cancer spinal metastasis: a retrospective cohort study

BACKGROUND CONTEXT

The current standard of care for prediction of survival of cancer staging is based on TNM staging. However, for patients with spinal metastasis, who all have identical stage IV disease, identifying accurate prognostic markers of survival would allow better treatment stratification between more aggressive treatment strategies or palliation. Analytical morphometrics enables physicians to quantify patient frailty by measuring lean muscle mass. Morphometrics also predicts survival in patients with lung cancer metastases to the spine.

PURPOSE

Our study evaluates whether morphometrics is predictive of survival in patients with breast cancer spinal metastasis.

DESIGN

This is an observational retrospective cohort study.

PATIENT SAMPLE

This study includes female patients with breast cancer spinal metastases and patients who have undergone stereotactic body radiation therapy.

OUTCOME MEASURES

Overall survival was the primary outcome measure.

METHODS

Morphometric measurements of the psoas muscle were taken using computed tomography scans of the lumbar spine. We then stratified patients into tertiles based on the psoas muscle area.

RESULTS

We identified 118 patients, with a median survival of 104 days (95% confidence interval [CI]=73-157 days). Overall survival was not associated with age, chemotherapy, or number of levels radiated. Patients in the lowest tertile of psoas size had significantly shorter survival compared with the highest tertile (68 days versus 148 days, hazard ratio 1.76 [95% CI=1.08-2.89], p=.024). The shorter survival was also true for the lowest tertile versus the middle tertile (68 days versus 167 days, hazard ratio 1.95 [95% CI=1.19-3.19], p=.007). Kaplan-Meier survival curves were used to visually illustrate the differences in survival between different tertiles.

CONCLUSIONS

Morphometric analysis of the psoas muscle size in patients with breast cancer metastases to the spine was effective in identifying patients at risk of shorter survival. Further research is needed to validate these results, as well as to see if these methodologies can be applied to other cancer histologies.

Morphometrics predicts overall survival in patients with multiple myeloma spine metastasis: A retrospective cohort study

Background

Treatment strategies for spinal metastases for myeloma range from conservative measures (radiation and chemotherapy) to invasive (surgical). Identifying better predictors of overall survival (OS) would help in surgical decision making. Analytic morphometrics has been shown to predict survival in oncologic patients, and our study evaluates whether morphometrics is predictive of survival in patients with multiple myeloma (MM) spinal metastases.

Methods

For this observational retrospective cohort study, we identified 46 patients with MM spinal metastases who had undergone stereotactic body radiation therapy. OS was the primary outcome measure. Morphometric analysis of the psoas muscle was performed using computed tomography scans of the lumbar spine.

Results

OS was statistically correlated with age (P = 0.025), tumor burden (P = 0.023), and number of levels radiated (P = 0.029), but not with gender. Patients in the lowest tertile of average psoas size had significantly shorter survival compared to the highest tertile, hazard ratio (HZ) 6.87 (95% CI = 1.65-28.5, P = 0.008). When calculating the psoas size to vertebral body ratio and correlating this measure to OS, the lowest tertile again had significantly shorter OS compared to the highest tertile, HZ 6.87 (95% CI = 1.57-29.89, P = 0.010); the middle tertile also showed significantly shorter OS compared to the highest tertile, HZ 5.07 (95% CI = 1.34-19.10, P = 0.016). Kaplan-Meier survival curves were used to visually illustrate the differences in survival between different tertiles (Log-rank test P = 0.006).

Conclusions

Morphometric analysis successfully predicts long-term survival in patients with MM. More research is needed to validate these results and to see if these methodologies can be applied to other cancer histologies.

Determining the impact of sarcopenia on postoperative complications after ventral hernia repair

BACKGROUND

Postoperative complication following ventral hernia repair (VHR) is a major clinical and financial burden. Preoperative risk assessment is necessary to minimize adverse outcomes following VHR. This study examines the ability of an independent parameter to predict postoperative morbidity following VHR.

METHODS

A retrospective analysis of 58 patients who underwent VHR by component separation between January 2009 and December 2013 was performed. Preoperative abdominal CT scans were analyzed to assess sarcopenia. Sarcopenia was determined using the Hounsfield unit average calculation (HUAC), a measure of psoas muscle size and density. Sarcopenia was defined as an HUAC score of less than 19.6 HU calculated using receiver operating characteristic (ROC) analysis and the Youden index. Multivariate analysis was performed to analyze the association of sarcopenia and postoperative complications.

RESULTS

Preoperative sarcopenia was associated with an increased risk for postoperative complications (odds ratio [OR] = 5.3; p = 0.04). Preexisting gastrointestinal conditions such as ulcerative colitis or colon cancer were associated with an increased risk for postoperative complications (OR = 5.7; p = 0.05). A significantly higher rate of hernia recurrence (33.3% vs. 10.8% [p = 0.04]) and renal failure (19% vs. 2.7% [p = 0.03]) was noted in patients with sarcopenia when compared to patients without sarcopenia.

CONCLUSIONS

Sarcopenia is an independent risk factor for postoperative complications in patients who underwent VHR. Assessment of sarcopenia using the HUAC score provides an opportunity for the adjustment of perioperative care plans to minimize postoperative complication rates.

Systematic review and meta-analysis of frailty as a predictor of morbidity and mortality after major abdominal surgery

Background

Frailty is associated with poor prognosis, but the multitude of definitions and scales of assessment makes the impact on outcomes difficult to assess. The aim of this study was to quantify the effect of frailty on postoperative morbidity and mortality, and long‐term mortality after major abdominal surgery, and to evaluate the performance of different frailty metrics.

Methods

An extended literature search was performed to retrieve all original articles investigating whether frailty could affect outcomes after elective major abdominal surgery in adult populations. All possible definitions of frailty were considered. A random‐effects meta‐analysis was carried out for all outcomes of interest. For postoperative morbidity and mortality, overall effect sizes were estimated as odds ratios (OR), whereas the hazard ratio (HR) was calculated for long‐term mortality. The potential effect of the number of domains of the frailty indices was explored through meta‐regression at moderator analysis.

Results

A total of 35 studies with 1 153 684 patients were analysed. Frailty was associated with a significantly increased risk of postoperative major morbidity (OR 2·56, 95 per cent c.i. 2·08 to 3·16), short‐term mortality (OR 5·77, 4·41 to 7·55) and long‐term mortality (HR 2·71, 1·63 to 4·49). All domains were significantly associated with the occurrence of postoperative major morbidity, with ORs ranging from 1·09 (1·00 to 1·18) for co‐morbidity to 2·52 (1·32 to 4·80) for sarcopenia. No moderator effect was observed according to the number of frailty components.

Conclusion

Regardless of the definition and combination of domains, frailty was significantly associated with an increased risk of postoperative morbidity and mortality after major abdominal surgery.

Impact of Sarcopenic Obesity on Failure to Rescue from Major Complications Following Pancreaticoduodenectomy for Cancer: Results from a Multicenter Study

BACKGROUND

Failure to rescue (FTR) is a quality-of-care indicator in pancreatic surgery, but may also identify patients who may not tolerate major postoperative complications despite being treated with best available care. Previous studies found that high visceral adipose tissue-to-skeletal muscle ratio is associated with poor outcomes following pancreaticoduodenectomy (PD). The aim of the study is to assess the impact of sarcopenic obesity on occurrence of FTR from major complications in cancer patients undergoing PD.

METHODS

Prospectively collected data from three high-volume hospitals were reviewed. Total abdominal muscle area (TAMA) and visceral fat area (VFA) were assessed at preoperative staging computed tomography scan. Sarcopenic obesity was defined as high VFA/TAMA ratio. FTR was defined as postoperative mortality following major complication.

RESULTS

120 patients with major complications were included. FTR occurred in 23 (19.2%) patients. The "seminal" complications leading to FTR were pancreatic or biliary fistula-related sepsis (n = 14), postoperative pancreatic fistula (POPF)-related hemorrhage (n = 5), and duodenojejunal anastomosis leak-related sepsis (n = 1). On univariate analysis, older age [odds ratio (OR) 3.5, p = 0.034], American Society of Anesthesiologists (ASA) score 3+ (OR 4.2, p = 0.005), cardiovascular disease (OR 3.3, p = 0.013), low serum albumin (OR 2.6, p = 0.042), sarcopenic obesity (OR 4.2, p = 0.009), POPF (OR 3.1, p = 0.027), and cardiorespiratory complications (OR 3.7, p = 0.011) were significantly associated with FTR. On multivariate analysis, sarcopenic obesity [OR 5.7, 95% confidence interval (CI) 1.6-20.7, p = 0.008], ASA score 3+ (OR 4.1, 95% CI 1.2-14.3, p = 0.025), and pancreatic fistula (OR 3.2, 95% CI 1.0-10.2, p = 0.045) were independently associated with FTR.

CONCLUSION

Sarcopenic obesity, low preoperative physical status, and occurrence of pancreatic fistula are associated with significantly higher risk of FTR from major complications after PD.

Sarcopenia/Muscle Mass is not a Prognostic Factor for Short- and Long-Term Outcome After Esophagectomy for Cancer

Background

Recent studies have suggested that sarcopenia is a prognostic risk indicator of postoperative complications and predicts survival in cancer patients. The aim of this study is to investigate whether sarcopenia is associated with postoperative short-term outcome (morbidity and mortality) and long-term survival in patients undergoing esophagectomy for cancer after neoadjuvant chemoradiotherapy.

Methods

All patients who underwent neoadjuvant chemoradiotherapy followed by esophagectomy for cancer, and of whom an adequate CT scan was available, were included in the current study. The presence of sarcopenia was defined by CT imaging using cut-off values of the total cross-sectional muscle tissue measured transversely at the third lumbar level.

Results

A total number of 120 patients were eligible for analysis. Almost half of the patients (N = 54, 45 %) were classified as having sarcopenia; 24 sarcopenic patients (44 %) had overweight and 5 sarcopenic patients (9 %) were obese. Overall morbidity and mortality rate did not differ significantly between sarcopenic and non-sarcopenic patients, nor did long-term overall or disease-free survival. Also sarcopenic obesity was not associated with worse outcome.

Conclusion

The presence of sarcopenia was not associated with a negative short- and long-term outcome in this selected group of esophageal cancer patients after neoadjuvant chemoradiotherapy followed by esophagectomy.

Poor Nutrition Status and Lumbar Spine Fusion Surgery in the Elderly: Readmissions, Complications, and Mortality

STUDY DESIGN

Retrospective database review.

OBJECTIVE

To quantify the medical and surgical risks associated with elective lumbar spine fusion surgery in patients with poor preoperative nutritional status and to assess how nutritional status alters length of stay and readmission rates.

SUMMARY OF BACKGROUND DATA

There has been recent interest in quantifying the increased risk of complications caused by frailty, an important consideration in elderly patients that is directly related to comorbidity burden. Preoperative nutritional status is an important contributor to both sarcopenia and frailty and is poorly studied in the elderly spine surgery population.

METHODS

The full 100% sample of Medicare data from 2005 to 2012 were utilized to select all patients 65 to 84 years old who underwent elective 1 to 2 level posterior lumbar fusion for degenerative pathology. Patients with diagnoses of poor nutritional status within the 3 months preceding surgery were selected and compared with a control cohort. Outcomes that were assessed included major medical complications, infection, wound dehiscence, and mortality. In addition, readmission rates and length of stay were evaluated.

RESULTS

When adjusting for demographics and comorbidities, malnutrition was determined to result in significantly increased odds of both 90-day major medical complications (adjusted odds ratio, OR: 4.24) and 1-year mortality (adjusted OR: 6.16). Multivariate analysis also demonstrated that malnutrition was a significant predictor of increased infection (adjusted OR: 2.27) and wound dehiscence (adjusted OR: 2.52) risk. Length of stay was higher in malnourished patients, though 30-day readmission rates were similar to controls.

CONCLUSION

Malnutrition significantly increases complication and mortality rates, whereas also significantly increasing length of stay. Nutritional supplementation before surgery should be considered to optimize postoperative outcomes in malnourished individuals.

LEVEL OF EVIDENCE

3.

Application of morphometric analysis to patients with lung cancer metastasis to the spine: a clinical study

OBJECTIVE Predicting the survival rate for patients with cancer is currently performed using the TNM Classification of Malignant Tumors (TNM). Identifying accurate prognostic markers of survival would allow better treatment stratification between more aggressive treatment strategies or palliation. This is especially relevant for patients with spinal metastases, who all have identical TNM staging and whose surgical decision-making is potentially complex. Analytical morphometrics quantifies patient frailty by measuring lean muscle mass and can predict risk for postoperative morbidity after lumbar spine surgery. This study evaluates whether morphometrics can be predictive of survival in patients with spinal metastases. METHODS Utilizing a retrospective registry of patients with spinal metastases who had undergone stereotactic body radiation therapy, the authors identified patients with primary lung cancer. Morphometric measurements were taken of the psoas muscle using CT of the lumbar spine. Additional morphometrics were taken of the L-4 vertebral body. Patients were stratified into tertiles based on psoas muscle area. The primary outcome measure was overall survival, which was measured from the date of the patient's CT scan to date of death. RESULTS A total of 168 patients were identified, with 54% male and 54% having multiple-level metastases. The median survival for all patients was 185.5 days (95% confidence interval [CI] 146-228 days). Survival was not associated with age, sex, or the number of levels of metastasis. Patients in the smallest tertile for the left psoas area had significantly shorter survival compared with a combination of the other two tertiles: 139 days versus 222 days, respectively, hazard ratio (HR) 1.47, 95% CI 1.06-2.04, p = 0.007. Total psoas tertiles were not predictive of mortality, but patients whose total psoas size was below the median size had significantly shorter survival compared with those greater than the median size: 146 days versus 253.5 days, respectively, HR 1.43, 95% CI 1.05-1.94, p = 0.025. To try to differentiate small body habitus from frailty, the ratio of psoas muscle area to vertebral body area was calculated. Total psoas size became predictive of mortality when normalized to vertebral body ratio, with patients in the lowest tertile having significantly shorter survival (p = 0.017). Left psoas to vertebral body ratio was also predictive of mortality in patients within the lowest tertile (p = 0.021). Right psoas size was not predictive of mortality in any calculations. CONCLUSIONS In patients with lung cancer metastases to the spine, morphometric analysis of psoas muscle and vertebral body size can be used to identify patients who are at risk for shorter survival. This information should be used to select patients who are appropriate candidates for surgery and for the tailoring of oncological treatment regimens.

Computed tomography abbreviated assessment of sarcopenia following trauma: The CAAST measurement predicts 6-month mortality in older adult trauma patients

BACKGROUND

Older adult trauma patients are at increased risk of poor outcome, both immediately after injury and beyond hospital discharge. Identifying patients early in the hospital stay who are at increased risk of death after discharge can be challenging.

METHODS

Retrospective analysis was performed using our trauma registry linked with the social security death index from 2010 to 2014. Age was categorized as 18 to 64 and 65 years or older. We calculated mortality rates by age category then selected elderly patients with mechanism of injury being a fall for further analysis. Computed Tomography Abbreviated Assessment of Sarcopenia for Trauma (CAAST) was obtained by measuring psoas muscle cross-sectional area adjusted for height and weight. Kaplan-Meier survival analysis was performed, and proportional hazards regression modeling was used to determine independent risk factors for in-hospital and out-of-hospital mortality.

RESULTS

A total of 23,622 patients were analyzed (16,748, aged 18-64 years; and 6,874, aged 65 or older). In-hospital mortality was 1.96% for ages 18 to 64 and 7.19% for age 65 or older (p < 0.001); postdischarge 6-month mortality was 1.1% for ages 18 to 64 and 12.86% for age 65 or older (p < 0.001). Predictors of in-hospital and postdischarge mortality for ages 18 to 64 and in-hospital mortality for ages 65 or older group included injury characteristics such as ISS, admission vitals, and head injury. Predictors of postdischarge mortality for age 65or older included skilled nursing before admission, disposition, and mechanism of injury being a fall. A total of 57.5% (n = 256) of older patients who sustained a fall met criteria for sarcopenia. Sarcopenia was the strongest predictor of out-of-hospital mortality in this cohort with a hazard ratio of 4.77 (95% confidence interval, 2.71-8.40; p < 0.001).

CONCLUSION

Out of hospital does not assure out of danger for the elderly. Sarcopenia is a strong predictor of 6-month postdischarge mortality for older adults. The CAAST measurement is an efficient and inexpensive measure that can allow clinicians to target older trauma patients at risk of poor outcome for early intervention and/or palliative care services.

LEVEL OF EVIDENCE

Prognostic and epidemiologic study, level III.

The Gap Between Clinical Research and Standard of Care: A Review of Frailty Assessment Scales in Perioperative Surgical Settings

The elderly population in the United States is increasing exponentially in tandem with risk for frailty. Frailty is described by a clinically significant state where a patient is at risk for developing complications requiring increased assistance in daily activities. Frailty syndrome studied in geriatric patients is responsible for an increased risk for falls, and increased mortality. In efforts to prepare for and to intervene in perioperative complications and general frailty, a universal scale to measure frailty is necessary. Many methods for determining frailty have been developed, yet there remains a need to define clinical frailty and, therefore, the most effective way to measure it. This article reviews six popular scales for measuring frailty and evaluates their clinical effectiveness demonstrated in previous studies. By identifying the most time-efficient, criteria comprehensive, and clinically effective scale, a universal scale can be implemented into standard of care and reduce complications from frailty in both non-surgical and surgical settings, especially applied to the perioperative surgical home model. We suggest further evaluation of the Edmonton Frailty Scale for inclusion in patient care.

Morphometrics as a predictor of perioperative morbidity after lumbar spine surgery

OBJECT Improved objective assessments of perioperative risk after spine surgery are necessary to decrease postoperative morbidity and mortality rates. Morphometric analysis has proven utility in predicting postoperative morbidity and mortality in surgical disciplines. The aim of the present study was to evaluate whether morphometrics can be applied to the cases of patients undergoing lumbar spine surgery. METHODS The authors performed a retrospective review of the perioperative course of 395 patients who underwent lumbar surgery at their institution from 2013 to 2014. Preoperative risk factors such as age, diabetes, smoking, coronary artery disease, and body mass index (BMI) were recorded. Preoperative MRI was used to measure the psoas muscle area at the L-4 vertebra and paraspinal muscle area at the T-12 vertebra. Primary outcomes included unplanned return to the operating room, 30- and 90-day readmissions, surgical site infection, wound dehiscence, new neurological deficit, deep vein thrombosis, pulmonary embolism, myocardial infarction, urinary tract infection, urinary retention, hospital-acquired pneumonia, stroke, and prolonged stay in the intensive care unit. RESULTS The overall rate of adverse events was 30%, the most common event being urinary retention (12%). Greater age (p = 0.015) and tobacco usage (p = 0.026) were both significantly associated with complications for all patients, while diabetes, coronary artery disease, and high BMI were not. No surgery-related characteristics were associated with postoperative morbidity, including whether surgery required instrumentation, whether it was a revision, or the number of vertebral levels treated. Using multivariate regression analysis, male and female patients with the lowest psoas tertile had an OR of 1.70 (95% CI 1.04-2.79, p = 0.035) for having postoperative complications. Male patients in the lowest psoas tertile had an OR of 2.42 (95% CI 1.17-5.01, p = 0.016) for having a postoperative complication. The paraspinal muscle groups did not provide any significant data for postoperative morbidity, even after multivariate analysis. CONCLUSIONS The morphometric measurement of psoas muscle size may be a sensitive predictive tool compared with other risk factors for perioperative morbidity in male patients undergoing lumbar surgery.

Frailty measurement in research and clinical practice: A review

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

Incidence of Low Body Mass Index in the Elderly in Forensic Cases-A Possible Marker for Frailty Syndrome?

Diagnosing frailty syndrome at autopsy may be difficult if no adequate clinical history is provided. As low body mass index (BMI) may be associated with frailty in the elderly, the following study was undertaken to determine the percentage of medicolegal cases with BMIs < 18.5 in decedents aged over 75 years. Review was undertaken over three time periods: January to December 1986, January to December 2006, and January to December 2012. In 1986, 16% (15 of 93) of individuals aged ≥75 years had BMIs < 18.5, in 2006, 15% (50 of 336), and in 2012, 13% (35 of 274). In no case was frailty syndrome mentioned. This study demonstrates that frailty syndrome appears to be an underappreciated diagnosis in forensic practice despite a significant percentage of elderly decedents (13-16% over a 27-year period) having low BMIs. Prospective assessment of this group is required to determine the incidence and contribution to mortality of frailty syndrome in a forensic context.

Effect of sarcopenia and visceral obesity on mortality and pancreatic fistula following pancreatic cancer surgery

BACKGROUND

Analytical morphometric assessment has recently been proposed to improve preoperative risk stratification. However, the relationship between body composition and outcomes following pancreaticoduodenectomy is still unclear. The aim of this study was to assess the impact of body composition on outcomes in patients undergoing pancreaticoduodenectomy for cancer.

METHODS

Body composition parameters including total abdominal muscle area (TAMA) and visceral fat area (VFA) were assessed by preoperative staging CT in patients undergoing pancreaticoduodenectomy for cancer. Perioperative variables and postoperative outcomes (mortality or postoperative pancreatic fistula) were collected prospectively in the institutional pancreatic surgery database. Optimal stratification was used to determine the best cut-off values for anthropometric measures. Multivariable analysis was performed to identify independent predictors of 60-day mortality and pancreatic fistula.

RESULTS

Of 202 included patients, 132 (65·3 per cent) were classified as sarcopenic. There were 12 postoperative deaths (5·9 per cent), major complications developed in 40 patients (19·8 per cent) and pancreatic fistula in 48 (23·8 per cent). In multivariable analysis, a VFA/TAMA ratio exceeding 3·2 and American Society of Anesthesiologists grade III were the strongest predictors of mortality (odds ratio (OR) 6·76 and 6·10 respectively; both P < 0·001). Among patients who developed major complications, survivors had a significantly lower VFA/TAMA ratio than non-survivors (P = 0·017). VFA was an independent predictor of pancreatic fistula (optimal cut-off 167 cm(2) : OR 4·05; P < 0·001).

CONCLUSION

Sarcopenia is common among patients undergoing pancreaticoduodenectomy. The combination of visceral obesity and sarcopenia was the best predictor of postoperative death, whereas VFA was an independent predictor of pancreatic fistula.

Collagen peptide supplementation in combination with resistance training improves body composition and increases muscle strength in elderly sarcopenic men: a randomised controlled trial

Protein supplementation in combination with resistance training may increase muscle mass and muscle strength in elderly subjects. The objective of this study was to assess the influence of post-exercise protein supplementation with collagen peptides v. placebo on muscle mass and muscle function following resistance training in elderly subjects with sarcopenia. A total of fifty-three male subjects (72·2 (sd 4·68) years) with sarcopenia (class I or II) completed this randomised double-blind placebo-controlled study. All the participants underwent a 12-week guided resistance training programme (three sessions per week) and were supplemented with either collagen peptides (treatment group (TG)) (15 g/d) or silica as placebo (placebo group (PG)). Fat-free mass (FFM), fat mass (FM) and bone mass (BM) were measured before and after the intervention using dual-energy X-ray absorptiometry. Isokinetic quadriceps strength (IQS) of the right leg was determined and sensory motor control (SMC) was investigated by a standardised one-leg stabilisation test. Following the training programme, all the subjects showed significantly higher (P<0·01) levels for FFM, BM, IQS and SMC with significantly lower (P<0·01) levels for FM. The effect was significantly more pronounced in subjects receiving collagen peptides: FFM (TG +4·2 (sd 2·31) kg/PG +2·9 (sd 1·84) kg; P<0·05); IQS (TG +16·5 (sd 12·9) Nm/PG +7·3 (sd 13·2) Nm; P<0·05); and FM (TG -5·4 (sd 3·17) kg/PG -3·5 (sd 2·16) kg; P<0·05). Our data demonstrate that compared with placebo, collagen peptide supplementation in combination with resistance training further improved body composition by increasing FFM, muscle strength and the loss in FM.

Sarcopenia and frailty in elderly trauma patients

BACKGROUND

Sarcopenia describes a loss of muscle mass and resultant decrease in strength, mobility, and function that can be quantified by CT. We hypothesized that sarcopenia and related frailty characteristics are related to discharge disposition after blunt traumatic injury in the elderly.

METHODS

We reviewed charts of 252 elderly blunt trauma patients who underwent abdominal CT prior to hospital admission. Data for thirteen frailty characteristics were abstracted. Sarcopenia was measured by obtaining skeletal muscle cross-sectional area (CSA) from each patient's psoas major muscle using Slice-O-Matic(®) software. Dispositions were grouped as dependent and independent based on discharge location. χ (2), Fisher's exact, and logistic regression were used to determine factors associated with discharge dependence.

RESULTS

Mean age 76 years, 49 % male, median ISS 9.0 (IQR = 8.0-17.0). Discharge destination was independent in 61.5 %, dependent in 29 %, and 9.5 % of patients died. Each 1 cm(2) increase in psoas muscle CSA was associated with a 20 % decrease in dependent living (p < 0.0001). Gender, weakness, hospital complication, and cognitive impairment were also associated with disposition; ISS was not (p = 0.4754).

CONCLUSIONS

Lower psoas major muscle CSA is related to discharge destination in elderly trauma patients and can be obtained from the admission CT. Lower psoas muscle CSA is related to loss of independence upon discharge in the elderly. The early availability of this variable during the hospitalization of elderly trauma patients may aid in discharge planning and the transition to dependent living.

Frailty syndrome - Medicolegal considerations

The frailty syndrome refers to the concurrence of a number of specific clinical manifestations that include unintentional weight loss, decreased muscle mass (sarcopenia), exhaustion, reduced physical strength and activity, and slow ambulation. It involves multiple systems, is an increasing problem in elderly populations, and is strongly associated with increases in both morbidity and mortality. Despite its recognition clinically, the frailty syndrome is not often identified in forensic situations and is only infrequently mentioned in the associated literature. As there is a direct relationship between the frailty syndrome and significant adverse health outcomes the syndrome has clear medicolegal significance.

Advances in rehabilitation medicine

Rehabilitation medicine is the medical specialty that integrates rehabilitation as its core therapeutic modality in disability management. More than a billion people worldwide are disabled, and the World Health Organization has developed the International Classification of Functioning, Disability and Health as a framework through which disability is addressed. Herein, we explore paradigm shifts in neurorehabilitation, with a focus on restoration, and provide overviews on developments in neuropharmacology, rehabilitation robotics, virtual reality, constraint-induced therapy and brain stimulation. We also discuss important issues in rehabilitation systems of care, including integrated care pathways, very early rehabilitation, early supported discharge and telerehabilitation. Finally, we highlight major new fields of rehabilitation such as spasticity management, frailty and geriatric rehabilitation, intensive care and cancer rehabilitation.

The hallmarks of fibroblast ageing

Ageing is influenced by the intrinsic disposition delineating what is maximally possible and extrinsic factors determining how that frame is individually exploited. Intrinsic and extrinsic ageing processes act on the dermis, a post-mitotic skin compartment mainly consisting of extracellular matrix and fibroblasts. Dermal fibroblasts are long-lived cells constantly undergoing damage accumulation and (mal-)adaptation, thus constituting a powerful indicator system for human ageing. Here, we use the systematic of ubiquitous hallmarks of ageing (Lopez-Otin et al., 2013, Cell 153) to categorise the available knowledge regarding dermal fibroblast ageing. We discriminate processes inducible in culture from phenomena apparent in skin biopsies or primary cells from old donors, coming to the following conclusions: (i) Fibroblasts aged in culture exhibit most of the established, ubiquitous hallmarks of ageing. (ii) Not all of these hallmarks have been detected or investigated in fibroblasts aged in situ (in the skin). (iii) Dermal fibroblasts aged in vitro and in vivo exhibit additional features currently not considered ubiquitous hallmarks of ageing. (iv) The ageing process of dermal fibroblasts in their physiological tissue environment has only been partially elucidated, although these cells have been a preferred model of cell ageing in vitro for decades.

Urinary incontinence in the elderly and in the oldest old: correlation with frailty and mortality

Urinary incontinence (UI) is very common in the elderly and has personal and social implications. Many authors have pointed out the necessity to analyze UI in correlation with the overall quality of aging, to better understand this syndrome and define measures for its prevention and treatment. In the present study, we addressed this problem by analyzing the UI correlation with frailty, which has emerged in the last decade as the geriatric syndrome correlated with individual homeostatic capacity and then as the basis of the age-related physical decline. In addition, the monitoring of our sample for a long period allowed us to estimate the prognostic significance of UI by analyzing the correlation between UI and mortality. The analysis was performed in a large sample that included numerous ultra-nonagenarians, a population segment that is still poorly known for UI and other geriatric parameters. We found a strict correlation between UI and frailty, suggesting that UI is correlated to the homeostatic and physiological decline leading to frailty. In addition, we found that UI is an independent mortality risk factor in ultra-nonagenarians, suggesting that the neurological sensitivity needed to be continent is lost very soon when the frailty associated physiological decline begins. On the whole, our study suggests that UI is a marker of frailty and that UI patients should be monitored and, in case, treated in a timely manner to avoid, or to limit, the effects of frailty such as malnutrition, falls, and the consequent accumulation of disabilities.

Pulmonary Rehabilitation Increases Gait Speed in Patients With Chronic Lung Diseases

Introduction:

Gait speed provides an integrated index of physical performance; changes in gait speed could reflect deterioration in the underlying medical disorder or a response to medical/surgical interventions. Slower gait speeds reflect the overall level of impairment, especially in patients with chronic lung disease.

Methods:

We retrospectively reviewed the medical files of 119 patients who completed the pulmonary rehabilitation program at the University Medical Center in Lubbock, Texas, and collected demographic, pulmonary function, and 6-minute walk test information. Gait speed was calculated using the 6-minute walk test information.

Results:

The patients in this study had a mean age of 68.8 ± 10.1 years. Most patients (95) had chronic obstructive pulmonary disease/asthma. The mean forced expiratory volume in the first second of expiration (FEV1) was 1.3 ± 0.7 L (47.2% ± 19.7% predicted). The baseline gait speed was 41 ± 15 m/min before rehabilitation and 47 ± 15 m/min after rehabilitation. Baseline gait speed, body mass index, and FEV1 predicted postrehabilitation gait speed (P < .05 for each variable). Ten patients had a gait speed >60 m/min before rehabilitation; this number increased to 29 postrehabilitation. Using multivariable analysis, it was found that only the baseline gait speed predicted a speed of more than 60 m/min postrehabilitation. Seventy-four patients had an increase in 6-minute walk distance of greater than 30 m.

Conclusions:

Patients with chronic lung diseases have slow gait speeds. Most patients improve their speed with rehabilitation but do not increase their speed above 60 m/min and remain frail by this criterion. However, the majority of patients increase their walk distance by 30 m, a distance that represents a minimal clinically important distance.

The SHARE operationalized frailty phenotype: a comparison of two approaches

PURPOSE

the phenotype defined by Fried et al. is one of the main operationalizations of frailty. Santos-Eggimann et al. pioneered the adaptation of the phenotype criteria to the Survey of Health, Ageing and Retirement in Europe (SHARE, http://www.share-project.org/). Using the adapted criteria, Romero-Ortuno et al. created and validated the SHARE Frailty Instrument for Primary Care (SHARE-FI). In SHARE-FI, the cut-offs for the phenotypic categories (i.e. non-frail, pre-frail and frail) are automatically derived from latent variable modelling, while Fried et al. (and also Santos-Eggimann et al.) use a rule based on the number of criteria present (Ncriteria): ≥ 3: frail; 1 or 2: pre-frail; 0: non-frail. The aim of the present study was to compare the mortality prediction of these two different approaches (latent variable modelling in SHARE-FI vs. Ncriteria in Santos-Eggimann et al.).

SUBJECTS AND METHODS

the subjects were 15,420 women and 12,742 men from the first wave of SHARE. A correspondence analysis was used to assess the degree of agreement between phenotypic classifications. The ability of the continuous measures (Ncriteria and SHARE-FI score) to predict mortality (mean follow-up of 2.4 years) was compared using receiver operating characteristic plots and areas under the curve (AUC).

RESULTS

in both women and men, there was a high degree of correspondence between phenotypic categories. The two continuous measures performed similarly as mortality predictors (women: SHARE-FI-AUC = 0.77; Ncriteria-AUC = 0.75. Men: SHARE-FI-AUC = 0.76; Ncriteria-AUC = 0.72).

CONCLUSION

the two approaches to the SHARE operationalized frailty phenotype performed equally well to predict mortality.