Physical Function and Frailty Tools in Mortality Prediction of Middle-Aged Adults With HIV

Global frailty screening tools: Review and application of frailty screening tools from 2001 to 2023

As the aging population increases globally, health-related issues caused by frailty are gradually coming to light and have become a global health priority. Frailty leads to a significantly increased risk of falls, incapacitation, and death. Early screening leads to better prevention and management of frailty, increasing the possibility of reversing it. Developing assessment tools by incorporating disease states of older adults using effective interventions has become the most effective approach for preventing and controlling frailty. The most direct and effective tool for evaluating debilitating conditions is a frailty screening tool, but because there is no globally recognized gold standard, every country has its own scale for national use. The diversity and usefulness of the frailty screening tool has become a hot topic worldwide. In this article, we reviewed the frailty screening tool published worldwide from January 2001 to June 2023. We focused on several commonly used frailty screening tools. A systematic search was conducted using PubMed database, and the commonly used frailty screening tools were found to be translated and validated in many countries. Disease-specific scales were also selected to fit the disease. Each of the current frailty screening tools are used in different clinical situations, and therefore, the clinical practice applications of these frailty screening tools are summarized graphically to provide the most intuitive screening and reference for clinical practitioners. The frailty screening tools were categorized as (ⅰ) Global Frailty Screening Tools in Common; (ⅱ) Frailty Screening Tools in various countries; (ⅲ) Frailty Screening Tools for various diseases. As science and technology continue to advance, electronic frailty assessment tools have been developed and utilized. In the context of Coronavirus disease 2019 (COVID-19), electronic frailty assessment tools played an important role. This review compares the currently used frailty screenings tools, with a view to enable quick selection of the appropriate scale. However, further improvement and justification of each tool is needed to guide clinical practitioners to make better decisions.

Assessment, Prevalence, and Correlates of Frailty among Moroccan People Aged 50 and above Living with HIV

BACKGROUND

Persons living with HIV experience many challenges, such as premature aging and geriatric syndromes. Frailty has become an important determinant of a series of adverse health outcomes. This research aimed to evaluate the prevalence and risk factors for frailty in this population.

METHODS

A cross-sectional outpatient investigation was conducted in an urban HIV clinic. Patients aged 50 and older living with HIV were included. Frailty phenotype was evaluated using the original Fried criteria, and we calculated the Veterans Aging Cohort Study (VACS) index, Charlson Comorbidity Index, Fracture Risk Assessment Tool scores, and Mini-mental State Exam scores.

RESULTS

One hundred and nine individuals were studied. Ninety-two (84.4%) were men, with a mean age of 57.65.2 years. Fourteen (12.8%) participants were frail. Frail participants were older (P = 0.001) and less likely to be virally suppressed (P = 0.01). Having ≥3 comorbidities, VACS index, polypharmacy, and 5-year mortality risk was significantly greater in the frail group. Frailty was significantly associated with poorer quality of life (P = 0.02). The cognitive impairment, falls, and malnutrition risk were significantly associated with a risk to manifest a frail phenotype.

CONCLUSION

Frailty is common among Moroccans with HIV, and it is associated with greater morbidity and mortality rates. Our findings should serve as a warning sign to standardize frailty and geriatric syndrome screening in this population.

Health and sociodemographic factors associated with low muscle strength, muscle mass, and physical performance among people living with HIV

ABSTRACTThis study examined the factors associated with low muscle strength, muscle mass, and physical performance in 331 people living with HIV. Participants completed handgrip as a strength measure, appendicular skeletal muscle mass using bioimpedance analysis, and chair rise was a physical performance measure. Multivariate logistic regression was used to analyze the association between low values on these measures with sociodemographic, HIV-related factors, and comorbidities. Higher body mass index (BMI) (OR = 0.91; CI = 0.86-0.97) and higher CD4/CD8 ratio (OR = 0.38; 95% CI = 0.18-0.82) were associated with decreased likelihood of low handgrip strength. Being non-employed (OR = 2.08; 95% CI = 1.07-4.06), having hypertension (OR = 2.27; 95% CI = 1.13-4.54) and rheumatism (OR = 5.46; 95% CI = 1.68-17.74) increased the chance of low handgrip strength. Higher BMI (OR = 0.43; 95% CI = 0.34-0.56), CD4/CD8 ratio (OR = 0.29; 95% CI = 0.09-0.93), and bioimpedance phase angle (OR = 0.22; 95% CI = 0.12-0.40) were associated with decreased likelihood of low muscle mass. Lastly, having less than eight years of education (OR = 1.87; 95% CI = 1.02-3.41) and being non-employed (OR = 8.18; 95% CI = 3.09-21.61) increased the chance of low chair stand performance. In addition, higher CD4 + lymphocytes count (OR = 0.99; 95% CI = 0.99-0.99) was associated with a decreased likelihood of low chair stand performance. In conclusion, specific and non-specific HIV-related factors are associated with low handgrip strength, low muscle mass, and/or low chair stand performance.

Effects of frailty, geriatric syndromes, and comorbidity on mortality and quality of life in older adults with HIV

BACKGROUND

To understand the effects of frailty, geriatric syndromes, and comorbidity on quality of life and mortality in older adults with HIV (OAWH).

METHODS

Cross-sectional study of the FUNCFRAIL multicenter cohort. The setting was outpatient HIV-Clinic. OAWH, 50 year or over were included. We recorded sociodemographic data, HIV infection-related data, comorbidity, frailty, geriatric syndromes (depression, cognitive impairment, falls and malnutrition), quality of life (QOL) and the estimated risk of all-cause 5-year mortality by VACS Index. Association of frailty with geriatric syndromes and comorbidity was evaluated using the Cochran-Mantel-Haenszel test.

RESULTS

Seven hundred ninety six patients were included. 24.7% were women, mean age was 58.2 (6.3). 14.7% were 65 or over. 517 (65%) patients had ≥3 comorbidities, ≥ 1 geriatric syndrome and/or frailty. There were significant differences in the estimated risk of mortality [(frailty 10.8%) vs. (≥ 3 comorbidities 8.2%) vs. (≥ 1 geriatric syndrome 8.2%) vs. (nothing 6.2%); p = 0.01] and in the prevalence of fair or poor QOL [(frailty 71.7%) vs. (≥ 3 comorbidities 52%) vs. (≥ 1 geriatric syndrome 58.4%) vs. (nothing 51%); p = 0.01]. Cognitive impairment was significantly associated to mortality (8.7% vs. 6.2%; p = 0.02) and depression to poor QOL [76.5% vs. 50%; p = 0.01].

CONCLUSIONS

Frailty, geriatric syndromes, and comorbidity had negative effects on mortality and QOL, but frailty had the greatest negative effect out of the three factors. Our results should be a wake-up call to standardize the screening for frailty and geriatric syndromes in OAWH in the clinical practice.

TRIAL REGISTRATION

NCT03558438.

The association between physical frailty and injurious falls and all-cause mortality as negative health outcomes in people living with HIV: A systematic review and meta-analysis

OBJECTIVES

Physical frailty is one of the major concerns among older people living with HIV (PLWH). This meta-analysis aimed to explore the association between physical frailty and negative health outcomes among PLWH.

METHODS

We systematically searched six electronic databases including PubMed, Embase, Web of Science, the Cochrane Library, and Chinese databases up to April 10, 2022, for studies examining the association between physical frailty and risk of negative health outcomes among PLWH. Risk ratios (RRs), odds ratios, and hazard ratios with 95% CIs were extracted, and meta-analyses were conducted by using a fixed or random-effects model.

RESULTS

In total, 10 studies incorporating 7755 HIV-seropositive patients (mean age 49.4 years) were included in the meta-analysis. Overall, five studies with 3434 participants reported the effect of physical frailty on falls. Results showed that physical frailty in HIV-seropositive individuals demonstrated a higher risk of future falls (pooled RR 3.74, 95% CI 1.42-9.86) compared with robust HIV-seropositive patients. In addition, a meta-analysis of five studies (4321 participants) reporting the frailty-mortality association showed that physical frailty was significantly associated with a higher risk of all-cause mortality (RR 1.70, 95% CI 1.32-2.19) among PLWH.

CONCLUSION

Physical frailty is a significant risk factor for negative health outcomes in PLWH, including falls and all-cause mortality, underscoring the need for routine screening and early intervention of physical frailty among PLWH.

Aging Accelerates Postural Instability in HIV Infection: Contributing Sensory Biomarkers

People living with HIV infection (PWH) who are adequately treated pharmacologically are now likely to have a near normal life span. Along with this benefit of the aging HIV population are potential physical problems attendant to aging, including postural stability. Whether aging with HIV accelerates age-related liability for postural instability and what sensory factors contribute to imbalance were examined in 227 PWH and 137 people living without HIV (PWoH), age 25 to 75 years. A mixed cross-sectional/longitudinal design revealed steeper aging trajectories of the PWH than PWoH in sway path length, measured as center-of-pressure micro-displacements with a force platform while a person attempted to stand still. Sway paths were disproportionately longer for PWH than PWoH when tested with eyes closed than open. Multiple regression identified objective measures of sensory perception as unique predictors of sway path length, whereas age, sway path length, and self-reports of falls were predictors of standing on one leg, a common measure of ataxia. Knowledge about sensory signs and symptoms of imbalance in postural stability with and without visual information may serve as modifiable risk factors for averting instability and liability for falls in the aging HIV population.

Veterans Aging Cohort Study Index and Frailty: One Part of the Whole

In HIV medicine, the Veterans Aging Cohort Study (VACS) index is associated to some geriatric syndromes and has also been recently used as a proxy of frailty. However, using it as a proxy for the frailty phenotype may inadvertently interchange two different concepts. The purpose of this study was to evaluate to what extent the frailty phenotype may be explained by the index. Cross-sectional analysis included 393 participants with HIV aged 50 or older. Somers' delta (d) was calculated, and a multinomial logistic regression model was run to determine to what extent the VACS index scores explained the probability of being prefrail or frail. Mean age was 57.6 (standard deviation 6.5) years and 87.3% men. A weak, but positive association between the VACS 2.0 index score and the frailty phenotype was established (Somers' d = 0.120, p < .001). The multinomial logistic regression showed that prefrail and frail participants had higher probabilities for greater VACS index scores [OR = 1.05, 95% confidence intervals (CI) 1.01-1.09; p = .006 and OR = 1.17, 95% CI 1.09-1.26; p < .001, respectively]; however, VACS index only explained <12% of the variability observed in the frailty phenotype. High VACS index scores were associated with a greater probability of being frail; however, with a weak association. Thus, we should be cautious when using the VACS index as a general proxy of frailty, particularly for the frailty phenotype. However, the VACS index may be used as a means to identify persons who might benefit from further comprehensive geriatric assessment.

The Impact of Frailty on All-Cause Mortality in Patients with HIV Infection: A Systematic Review and Meta-Analysis

The aim of this study was to conduct a systematic review and meta-analysis of cohort studies that have examined the association between frailty and all-cause mortality in patients with HIV infection. We searched Embase, Medline through the Ovid interface, PubMed, Cochrane Library, and Web of Science to identify potential studies. Cohort studies of death outcomes in HIV patients under debilitating conditions were included and other ineligible or inadequate data were excluded. Data related to all-cause mortality in patients with HIV were extracted. The quality of the included studies was assessed using the Newcastle-Ottawa Scale for cohort studies. Hazard ratios (HRs) and their 95% confidence intervals (CIs) were pooled to estimate the association between frailty and all-cause mortality using Stata, version 12.0. We identified 845 unduplicated citations. Of these, six cohort studies were eligible for inclusion in the review after applying our inclusion and exclusion criteria. Pooled results demonstrated that patients with HIV experiencing frailty were at an increased risk of all-cause mortality (pooled HR = 2.69, 95% CI = 1.83-3.97, p < .001) compared with those without frailty. Frailty was significantly associated with an increased risk of all-cause mortality among patients with HIV, indicating that frailty is an important predictor of adverse clinical outcomes. Therefore, more attention should be paid to screen patients with HIV for frailty and adopt appropriate interventions and personalized treatment plans to prevent the occurrence of adverse events. However, these results need to be validated in further prospective cohort studies in ethnically or geographically diverse populations.

Sarcopenia in people living with HIV in Hong Kong: which definition correlates with health outcomes?

Introduction

Sarcopenia is an important clinical syndrome in older people living with HIV (PLWH). With a change to the Asia sarcopenia definition in 2019, we aimed to determine whether health outcomes were associated with different definitions of sarcopenia among Asian PLWH.

Methods

We performed a prospective cross‐sectional study enrolling PLWH aged ≥35 years from January 2018 to November 2021. We defined sarcopenia by the Asia Working Group of Sarcopenia (AWGS) criteria in 2014 and 2019. AWGS‐2014 included low muscle mass plus weak handgrip strength and/or slow gait speed. AWGS‐2019 included low muscle mass plus low muscle strength or physical performance, while the presence of all defines severe sarcopenia. We measured appendicular skeletal muscle mass using dual‐energy X‐ray absorptiometry, handgrip strength, usual gait speed, five‐time chair stand test and Short Physical Performance Battery. Correlations between each sarcopenia definition and health‐related quality of life (using EQ‐5D‐5L and SF‐36) and functional disability were determined.

Results

One hundred and fifty Asian PLWH were enrolled, 132 (88%) were male, mean age was 60±10 years, duration of HIV diagnosis was 13 (IQR 8–18) years and current CD4 count was 574 (IQR 362–762) cells/mm³, 67 (45%) had multimorbidity, 64 (43%) had polypharmacy. Prevalence of sarcopenia by AWGS‐2014, AWGS‐2019 and severe sarcopenia was 17.3%, 27.3% and 18.0%, respectively. Age, education and polypharmacy were associated with sarcopenia. Sarcopenia (AWGS‐2014) and severe sarcopenia were associated with mobility, physical functioning and physical component score (SF‐36). All three criteria were associated with impaired instrumental activities of daily living (IADL). After age and sex adjustment, sarcopenia (AWGS‐2014) (adjusted odds ratio/aOR 5.4, 95% confidence interval/CI 2.0–15.1) and severe sarcopenia (aOR 5.1, 95% CI 1.9–14.0) were associated with mobility and physical component score (SF‐36) (β coefficients –5.3342, p = 0.022 and –5.412, p = 0.019). Sarcopenia (AWGS 2014) (aOR 5.2, 95% CI 1.7–16.2), sarcopenia (AWGS‐2019) (aOR 4.5, 95% CI 1.5–13.1) and severe sarcopenia (aOR 3.5, 95% CI 1.1–10.9) were associated with impaired IADL in fully adjusted models.

Conclusions

In a sample of Asian PLWH, 17.3%, 27.3% and 18.0% had sarcopenia as defined by AWGS‐2014, AWGS‐2019 and severe sarcopenia, respectively. Sarcopenia by AWGS‐2014 and severe sarcopenia correlated with parameters of poor health outcomes, while sarcopenia by AWGS‐2019 correlated with functional disability.

Different profiles among older adults with HIV according to their chronological age and the year of HIV diagnosis: The FUNCFRAIL cohort study (GeSIDA 9817)

Background

People in their fifties with HIV are considered older adults, but they appear not to be a homogeneous group.

Objective

To evaluate the differences among older adults with HIV according to their chronological age and the year of HIV diagnosis.

Methods

Cross-sectional study of the FUNCFRAIL cohort. Patients 50 or over with HIV were included and were stratified by both chronological age and the year of HIV diagnosis: before 1996 (long-term HIV survivors [LTHS]) and after 1996. We recorded sociodemographic data, HIV-related factors, comorbidities, frailty, physical function, other geriatric syndromes, and quality of life (QOL).

Results

We evaluated 801 patients. Of these, 24.7% were women, 47.0% were LTHS, and 14.7% were 65 or over. Of the 65 or over patients, 73% were diagnosed after 1996. Higher rates of comorbidities among LTHS were found, being the more prevalent: COPD, history of cancer, osteoarthritis, depression, and other psychiatric disorders while the more prevalent among the 65 or over patients were: hypertension, diabetes, dyslipidemia, cancer, and osteoarthritis. LTHS showed a significantly worse QOL. There were no differences by the year of HIV diagnosis regarding frailty and functional impairment (SPPB <10) but they were more than twice as prevalent in the 65 or over patients compared to the other chronological age groups.

Conclusions

A LTHS and a 65 or over person are both “older adults with HIV,” but their characteristics and requirements differ markedly. It is mandatory to design specific approaches focused on the real needs of the different profiles.

Frailty in people living with HIV: an update

PURPOSE OF REVIEW

The HIV population is ageing with rising rates of frailty though strategies of how best to manage it remain ill-defined. It also remains unclear what the prevalence of frailty is within this cohort, how best to diagnose it and what factors are associated.

RECENT FINDINGS

The prevalence of frailty remains unclear because of heterogenous results. Routine screening in those 50+ is recommended and whilst the Fried Frailty Phenotype is currently preferred the Clinical Frailty Scale could be considered. No biomarkers are currently recommended. Looking at associated factors, HIV neurocognitive impairment and long-term alcohol usage has been shown to be associated with developing frailty whilst those who are frail have been shown to be less active and more likely to fall. NAFLD with fibrosis has been shown to be an indicator of metabolic age and the Pooled Cohort Equations has been shown to be more effective in diagnosing cardiovascular risk in frail people living with HIV.

SUMMARY

Whilst the prevalence of frailty differs between countries, with the addition of prefrailty, this represents a large proportion of people living with HIV. Services must ensure strategies are in place to support those living with HIV and frailty. Further longitudinal studies are required.

Comorbidities and psychosocial factors as correlates of self-reported falls in a nationwide sample of community-dwelling people aging with HIV in Germany

BACKGROUND

Falls are a frequent health problem with potentially severe consequences among the elderly. Due to the aging HIV population, there is a growing interest in falls as a geriatric syndrome in HIV research and clinical practice. Previous studies found rather high prevalences of falls in this population and focused on biomedical and demographic risk factors for falls. Psychosocial risk factors like stigma, social support or loneliness were not previously assessed as correlates of fall events in this population.

METHODS

We assessed self-reported fall frequency in the past 12 months in a nationwide sample of 897 community-dwelling people aged 50 years or older living with HIV in Germany using a cross-sectional study design. We calculated odds of any fall for sociodemographic and HIV-related variables in bivariate analyses and for comorbidities, and psychosocial variables in bivariate and adjusted analyses.

RESULTS

Eighteen percent of our participants reported at least one fall in the preceding 12 months, 12 % reported recurring falls. A lower socioeconomic status, being single and living alone were significantly associated with a higher risk for falling. An AIDS diagnosis was related to fall risk, but time since diagnosis and a detectable viral load were not. Reporting at least one comorbidity increased fall risk in our sample 2.5 times (95% CI: 1.59; 3.97). The strongest association with fall risk was found for diseases of the central nervous system, heart disease, rheumatism, osteoporosis, and chronic pain. Experienced HIV stigma (AOR: 2.11; 95% CI: 1.58; 2.83) and internalized HIV stigma (AOR: 1.43; 95% CI: 1.12; 1.85), as well as social support (AOR: .92; 95% CI: .86; .99) and loneliness (AOR: 1.51; 95% CI: 1.22; 1.87) were significantly related to fall risk in bivariate and adjusted analyses.

CONCLUSIONS

We found a low prevalence of falls in our sample of community-dwelling people aging with HIV. Our results show evidence for a strong association between comorbidity and falling, and between psychosocial factors and falling. Especially the strong association between experienced HIV stigma and fall risk is noteworthy and adds falls to the list of health outcomes affected by HIV stigma.

Assessment, prevalence, and correlates of frailty among middle-aged adults with HIV in rural Uganda

We investigated the prevalence and risk factors for frailty among people with HIV (PWH) in rural Uganda (n = 55, 47% male, mean age 44 years). Frailty was defined according to the Fried criteria with self-reported physical activity level replacing the Minnesota Leisure Time Activity Questionnaire. Alternate classifications for physical activity utilized were the sub-Saharan Africa Activity Questionnaire and the International Physical Activity Questionnaire. Eleven participants (19%) were frail. Frail participants were older (p < 0.001), less likely to be on antiretroviral therapy (p = 0.03), and had higher rates of depression (p < .001) and HIV-associated neurocognitive disorder (p = 0.003). Agreement between physical activity measures was sub-optimal. Prevalence of frailty was high among PWH in rural Uganda, but larger sample sizes and local normative data are needed.

Low Agreement Between Initial and Revised European Consensus on Definition and Diagnosis of Sarcopenia Applied to People Living With HIV

BACKGROUND

In 2019, the European Working Group on Sarcopenia in Older People (EWGSOP2) proposed low muscle strength as the primary outcome for sarcopenia diagnosis instead of low muscle mass, as proposed in 2010 (EWGSOP1). Therefore, the aim of this study was to compare the prevalence of sarcopenia using both EWGSOP1 and EWGSOP2 operational definitions in people living with HIV (PLHIV) and to determine the agreement and correlation between different tests proposed by EWGSOP2.

SETTING

Cross-sectional study, where 302 PLHIV (151 men), 51.7 ± 9.0 years old were evaluated for the presence of sarcopenia using both EWGSOP1 and EWGSOP2 operational definitions.

METHODS

Appendicular skeletal muscle was estimated using bioimpedance analysis. Handgrip strength, chair stand, gait speed, and static balance were used as muscle function measures. Agreement was determined using Cohen kappa and Pearson correlation coefficient was calculated.

RESULTS

Sarcopenia prevalence was 4.3% using EWGSOP1 and 1.0% using EWGSOP2. Agreement for sarcopenia diagnosis between EWGSOP1 and EWGSOP2 was fair (k = 0.37, P < 0.01). From the 13 cases of sarcopenia diagnosed using EWGSOP1, only 3 cases (23.1%) were also diagnosed using EWGSOP2. A medium correlation (r = -0.32, P < 0.01) and poor agreement (k = 0.14, P < 0.01) between muscle strength tests (handgrip strength and chair stand) were observed. Concordance between handgrip and chair stand was observed in 11 participants only, whereas 65 participants were considered to have low muscle strength using chair stand but not using handgrip.

CONCLUSIONS

Lower sarcopenia prevalence using EWGSOP2 and low agreement between EWGSOP1 and EWGSOP2 operational definitions in diagnosing sarcopenia were observed in PLHIV.