Psychological contributors to the frail phenotype: The association between resilience and frailty in patients with cirrhosis

Frailty after Liver Transplantation: A Complex Unexplored Issue

Frailty is a multidimensional syndrome predominantly studied in the elderly, characterized by reduced resistance to stressors due to diminished physiological reserve and resilience. Advances in surgical techniques and immunosuppressive drugs have improved long-term survival rates in solid organ transplant recipients, yet the 10-year survival is satisfying. However, liver transplant recipients have a noteworthy risk of developing frailty status. After liver transplant, frailty can be favored by socioeconomic, cultural, and health-related factors, leading to increased risks of hospitalization, morbidity, and mortality. Various tools for frailty assessment exist, but none are universally validated for post-transplant patients. The integration of socioeconomic and psychological factors into frailty evaluation could improve quality of life and long-term outcomes for transplant recipients. Multidisciplinary approaches, including psychosocial support, are essential for managing frailty and enhancing the overall care of transplanted patients. This narrative review aims to comprehensively address the principal frailty risk factors associated with liver transplantation.

Prevalence of Frailty and Its Impact on Mortality and Hospitalization in Patients With Cirrhosis: A Systematic Review and Meta-analysis

Background & aims

Frailty in patients with cirrhosis is associated with increased morbidity and mortality. In this study, we aimed to determine the prevalence of frailty and its impact on mortality and hospitalization in patients with cirrhosis.

Methods

An elaborate search was undertaken in the databases "PubMed, Scopus, Web of Science, and Cochrane, and preprint servers", and an assessment of all published articles till 17 February 2023 was done. Studies that provided data on prevalence, mortality and hospitalization among frail patients with cirrhosis were included. The study characteristics and data on the prevalence, mortality, and hospitalization were extracted from included studies. The primary outcome was to estimate the pooled prevalence of frailty and determine its impact on mortality and hospitalization in patients with cirrhosis.

Results

Overall, 12 studies were included. Data on prevalence of frailty and mortality were available in 11 studies, while seven studies reported data on hospitalization. The analysis conducted among 6126 patients with cirrhosis revealed pooled prevalence of frailty to be 32% (95% confidence interval [CI], 24-41). A total of 540 events of death revealed a pooled mortality rate of 29% (95% CI, 19-41). Six-month and twelve-month pooled estimates of mortality were found to be 24% (95% CI, 17-33) and 33% (95% CI, 23-45), respectively. The pooled hospitalization rate among the seven studies was 43% (95% CI, 21-68).

Conclusion

The prevalence of frailty in patients with cirrhosis is high, leading to poor outcomes. Frailty assessment should become an integral part of cirrhosis evaluation.

Registry and registration number of study

PROSPERO 2022 CRD42022377507.

Frailty in liver transplantation: Exploring prescribing exercise as medicine to improve patient outcomes

Liver transplantation (LT) represents a curative avenue for individuals with advanced chronic liver disease. Given the inherent illness severity of LT candidates, identifying patients at greater risk for adverse outcomes before and after transplantation is paramount. Approximately 50% of cirrhotic patients are frail and have considerable functional impairment. Various measures have been used to assess frailty, including performance-based tests and functional status evaluations. Frailty carries significant prognostic implications and predicts both mortality and pre- and post-LT complications. Contributing factors to frailty in this population include sarcopenia, malnutrition, inflammation, and psychosocial factors. Recognizing the prevalence of frailty among LT candidates, exercise interventions have been developed to improve physical frailty and offer potential to improve patient outcomes. While many interventions have demonstrated efficacy without notable adverse events, the absence of a universally accepted standard for exercise prescription underscores the variability in intervention elements and patient adherence. Given the safety profile of exercise interventions, there remains a critical need for standardized protocols and guidelines to optimize exercise regimens for LT candidates. This review delves into the landscape of frailty among LT candidates, elucidating its etiological underpinnings, impact on outcomes, utilization of exercise interventions, and the efficacy of exercise programs in reducing the burden frailty in those awaiting LT.

Harnessing physical activity monitoring and digital biomarkers of frailty from pendant based wearables to predict chemotherapy resilience in veterans with cancer

This study evaluated the use of pendant-based wearables for monitoring digital biomarkers of frailty in predicting chemotherapy resilience among 27 veteran cancer patients (average age: 64.6 ± 13.4 years), undergoing bi-weekly chemotherapy. Immediately following their first day of chemotherapy cycle, participants wore a water-resistant pendant sensor for 14 days. This device tracked frailty markers like cadence (slowness), daily steps (inactivity), postural transitions (weakness), and metrics such as longest walk duration and energy expenditure (exhaustion). Participants were divided into resilient and non-resilient groups based on adverse events within 6 months post-chemotherapy, including dose reduction, treatment discontinuation, unplanned hospitalization, or death. A Chemotherapy-Resilience-Index (CRI) ranging from 0 to 1, where higher values indicate poorer resilience, was developed using regression analysis. It combined physical activity data with baseline Eastern Cooperative Oncology Group (ECOG) assessments. The protocol showed a 97% feasibility rate, with sensor metrics effectively differentiating between groups as early as day 6 post-therapy. The CRI, calculated using data up to day 6 and baseline ECOG, significantly distinguished resilient (CRI = 0.2 ± 0.27) from non-resilient (CRI = 0.7 ± 0.26) groups (p < 0.001, Cohen's d = 1.67). This confirms the potential of remote monitoring systems in tracking post-chemotherapy functional capacity changes and aiding early non-resilience detection, subject to validation in larger studies.

Association between resilience and frailty in older age: Findings from the Helsinki Birth Cohort Study

OBJECTIVES

Resilience, a capacity to cope with adversity, has been linked to better functioning and health in older age. However, little is still known about resilience in relation to frailty. We explored whether resilience would be associated with frailty in older age and if we would observe differences in association between resilience and frailty according to the type of adversity.

METHODS

The study included 681 participants from the Helsinki Birth Cohort Study, born in Helsinki between 1934 and 1944. Adversities in older age and resilience were assessed between 2015 and 2018 with the Hardy-Gill resilience scale, scores ranging from 0 (low) to 18 (high resilience). Frailty was assessed in 2017-18 by using a deficit accumulation-based Frailty Index with a scale from 0 to 1. Adversities were coded into categories by using a data-driven approach. A linear regression analysis was used to explore the association between resilience and frailty.

RESULTS

Resilience was inversely associated with frailty in older age (β -0.009, 95% CI -0.011 to -0.007, p<0.001). The association was observed for all other type of adversities except adversity in relationships and economical adversity.

DISCUSSION

A higher resilience was related to lower levels of frailty in older age. Differences in association between resilience and frailty were observed according to the type of adversity. Focusing on the type of adverse events and the capacity to "bounce back" after an adversity in older age may reveal new perspectives on how to prevent and postpone frailty.

Transitions in robust and prefrail octogenarians after 1 year: the influence of activities of daily living, social participation, and psychological resilience on the frailty state

BACKGROUND

Knowledge opportunities lie ahead as everyday activities, social participation, and psychological resilience might be important predictors for frailty state transitioning in the oldest old. Therefore, this article aims to examine whether changes in basic-, instrumental-, advanced- activities of daily living (b-, i-, a-ADLs), social participation, and psychological resilience predict both a transition from robustness to prefrailty or frailty and vice versa among community-dwelling octogenarians over a follow-up period of one year.

METHODS

To evaluate worsened and improved frailty transitions after one year in 322 octogenarians (Mage = 83.04 ± 2.78), the variables sex, ADLs (b-ADL-DI, i-ADL-DI, a-ADL-DI as baseline and as difference after 6 months values), the CD-RISC (Connor-Davidson Resilience Scale, as baseline and as difference after 6 months), the social participation variables (total participation score, being a member, total number of memberships, level of social participation, being a board member, volunteering, and formal participation as baseline and as difference after 6 months values), were included in a logistic regression analysis.

RESULTS

Limitations in a-ADLs at baseline (OR: 1.048, 95% confidence interval, 1.010-1.090) and an increment of limitations in a-ADLs after 6 months (OR: 1.044, 95% confidence interval, 1.007-1.085) were predictors to shift from robust to a worsened frailty state after one year follow-up. Additionally, being a woman (OR: 3.682, 95% confidence interval, 1.379-10.139) and social participation, specifically becoming a board member in 6 months (OR: 4.343, 95% confidence interval, 1.082-16.347), were protectors of robustness and thus related to an improved frailty transition after one year.

CONCLUSIONS

Encouraging healthy lifestyle behaviors to help the maintenance of ADLs, possibly leading to more social participation, could be promising in the prevention of frailty.

Accumulating awareness on the clinical significance and relevance of frailty in cirrhosis: Time to dig deeper into mechanistic basis!

Frailty corresponds to an emerging construct in the hepatology which is originally introduced as a validated geriatric syndrome regarding increased vulnerability to pathophysiological stressors. As for patients with cirrhosis, the presence of frailty is indicative of debilitating conditions that subjects are prone to deleterious acute insults and have difficulties to restore even if the underlying liver function partially returned to normal levels. Since this conceptual development, a variety of tools assessing frailty have been proposed and evaluated in the context of cirrhosis. A recent performance-based metric for frailty, designated as Liver Frailty Index, has broadly been applied in patients with cirrhosis and exhibited acceptable predictive ability in relation to disease progression, mortality and hospitalization. However, those functional tests measuring frailty may be impossible to perform in circumstance that patients are critically ill or undergoing detrimental events. An interesting modality indicates the use of alternative tests to evaluate frailty, which may be more adaptable and of choice for specific subgroups. The interrelation between frailty and various cirrhosis-associated pathological entities is of clinical importance and implication. Noticeably, it is imperative to clarify these complex linkages to highlight novel therapeutic targets or interventional endpoints. The efficient and effective management of frailty is still challenging, but many attempts have been made to overcome barriers of affordability and availability. Some clinical trials on small scale revealed that home-based exercise and individualized nutrition therapy show benefits in patients with cirrhosis, and high adherence to the treatment regimen may direct better efficacy and performance.

Liver transplantation in the patient with physical frailty

Frailty is a decline in functional reserve across multiple physiological systems. A key component of frailty is sarcopenia, which denotes a loss of skeletal muscle mass and impaired contractile function that ultimately result in physical frailty. Physical frailty/sarcopenia are frequent and contribute to adverse clinical outcomes before and after liver transplantation. Frailty indices, including the liver frailty index, focus on contractile dysfunction (physical frailty), while cross-sectional image analysis of muscle area is the most accepted and reproducible measure to define sarcopenia. Thus, physical frailty and sarcopenia are interrelated. The prevalence of physical frailty/sarcopenia is high in liver transplant candidates and these conditions have been shown to adversely impact clinical outcomes including mortality, hospitalisations, infections, and cost of care both before and after transplantation. Data on the prevalence of frailty/sarcopenia and their sex- and age-dependent impact on outcomes are not consistent in patients on the liver transplant waitlist. Physical frailty and sarcopenic obesity are frequent in the obese patient with cirrhosis, and adversely affect outcomes after liver transplantation. Nutritional interventions and physical activity remain the mainstay of management before and after transplantation, despite limited data from large scale trials. In addition to physical frailty, there is recognition that a global evaluation including a multidisciplinary approach to other components of frailty (e.g., cognition, emotional, psychosocial) also need to be addressed in patients on the transplant waitlist. Recent advances in our understanding of the underlying mechanisms of sarcopenia and contractile dysfunction have helped identify novel therapeutic targets.

A moderated mediation analysis of depression and age on the relationship between resilience and frailty among HIV-positive adults

Background

Given the continuing challenges frailty poses among people living with human immunodeficiency virus (HIV) (PLHIV), accumulating evidence suggests that frailty is linked to psychological factors. However, the mutual influences of resilience, depression, and frailty have not yet been clarified. This study aimed to identify the potential mechanistic pathway through which psychological factors mitigate frailty.

Methods

Data were collected from June to August 2019 by trained investigators through face-to-face interviews with 375 HIV-positive Chinese adults. Each participant completed structured questionnaires to collect data in respect of their socio-demographic characteristics, and levels of frailty, depression, and resilience. These assessment measures included a self-designed questionnaire, the Tilburg Frailty Indicator (TFI), the 10-item Center for Epidemiological Studies Depression Scale (CES-D-10), and the 10-item Connor-Davidson Resilience Scale (CD-RISC-10). SPSS PROCESS macro was used to analyze the mediation and moderated mediation models.

Results

The overall prevalence of frailty was 26.4%, and the prevalence of frailty among older and younger adults living with HIV was 22 and 31.4%, respectively. Mediation analysis showed that an association between resilience and frailty was mediated by depression, whereas resilience did not mediate the relationship between depression and frailty. Compared to physical frailty, depression was a stronger mediator of resilience to psychological frailty. We further found that age moderated the indirect effect of resilience on psychological frailty, with resilience being a stronger negative predictor of depression and depression being a stronger positive predictor of psychological frailty for older PLHIV than for younger PLHIV.

Conclusion

Lower levels of resilience and greater levels of depression may be significant risk factors for frailty among PLHIV. Levels of resilience influenced frailty directly and frailty was indirectly affected by depression. Therefore, it is recommended that PLHIV, especially older patients, should be encouraged to establish positive psychological coping strategies to slow the progression of frailty.

Loneliness in adults awaiting liver transplantation at 7 U.S. transplant centers

INTRODUCTION

Loneliness, "a subjective feeling of being isolated", is a strong predictor of adverse health. We characterized loneliness in patients with end-stage liver disease (ESLD) awaiting liver transplantation (LT).

METHODS

We surveyed loneliness in ambulatory ESLD adults awaiting LT at 7 U.S. sites using the validated UCLA Three-Item Loneliness Scale, May2020-Jan2021; "lonely"=total ≥5. Liver Frailty Index (LFI) assessed frailty; "frail"=LFI≥4.4. Logistic regression associated loneliness and co-variables.

RESULTS

Of 454 participants, median MELDNa was 14 (IQR 10-19) and 26% met criteria for "lonely". Compared to those not lonely, those lonely were younger (57 v. 61y), more likely to be female (48% v. 31%) or frail (21 v. 11%), and less likely to be working (15% v. 26%) or in a committed partnership (52% v. 71%). After multivariable adjustment, frailty (OR=2.24, 95%CI=1.23-4.08), younger age (OR=1.19, 95%CI=1.07-1.34), female sex (OR=1.83, 95%CI=1.14-2.92), not working (OR=2.16, 95%CI=1.16-4.03), and not in a committed partnership (OR=2.07, 95%CI=1.29-3.32) remained significantly associated with higher odds of loneliness.

CONCLUSION

Loneliness is prevalent in adults awaiting LT, and independently associated with younger age, female sex and physical frailty. These data lay the foundation to investigate the extent to which loneliness impacts health outcomes in LT, as in the general population. Clinical Trial Registry Website: https://clinicaltrials.gov Trial Number: NCT03228290.

Association between resilience and frailty among Chinese older adults

PURPOSE

Resilience is a multidimensional concept determining healthy aging, however, there were limited studies examining the association between frailty and resilience in detail. In this study, we aimed to examine the association of frailty with three dimensions of resilience-strength, optimism, and tenacity among Chinese older adults.

METHODS

A cross-sectional study was conducted among 10,209 participants who were sampled by three-stage sampling method, from three cities in China from June 2020 to July 2021. The Chinese version of the Connor-Davidson Resilience Scale (CD-RISC) was used to measure resilience's 3 dimensions (strength, optimism and tenacity), which were converted into quartiles for the analysis. Frailty status was measured using the Chinese version of the FRAIL scale, categorized into robustness, pre-frailty and frailty. Multinomial logistic regression was used to examine associations between frailty status with strength, optimism and tenacity.

RESULTS

The overall proportions of robustness, pre-frailty, and frailty were 42.7, 48.7, and 8.6%, respectively. After controlling for sociodemographic characteristics, self-rated health, and health behaviors, compared with older adults with the lowest quartile of strength, older adults with the second quartile (odds ratio, OR = 0.67, 95% CI: 0.57-0.78), third quartile (OR = 0.60, 95% CI: 0.50-0.72), and fourth quartile (OR = 0.58, 95% CI: 0.46-0.73) of strength had lower ORs for pre-frailty, and who also had lower ORs (0.44, 95% CI: 0.33-0.58; 0.42, 95% CI: 0.30-0.59; 0.34, 95% CI: 0.20-0.56, respectively) for frailty. There were no homogeneous associations between optimism and tenacity with frailty status.

CONCLUSION

Higher strength was associated with lower chance of being pre-frail and frail among Chinese older adults. This finding implies that community-based training programs aiming to enhance psychological resilience, especially strength, may contribute to healthy aging. Future studies should examine the effects of resilience on frailty using longitudinal or experimental study designs in cross-cultural contexts.

Does psychological resilience mediate the relation between daily functioning and prefrailty status?

OBJECTIVES

Understanding of prefrailty's relationship with limitations in activities of daily living (ADLs) moderated by psychological resilience is needed, as resilience might support ADLs' maintenance and thus protect against frailty. Therefore, this study aims to analyze the influence of psychological resilience (using the Connor-Davidson Resilience Scale; CD-RISC) on the relation between ADLs and frailty status of older individuals (i.e. prefrail versus robust).

DESIGN

Cross-sectional design.

SETTING

UZ Brussels, Belgium.

PARTICIPANTS

Robust (Fried 0/4;n = 214; Age = 82.3 ± 2.1yrs) and prefrail (Fried 1-2/4; n = 191; Age = 83.8 ±3.2yrs) community-dwelling older individuals were included.

MEASUREMENTS

Frailty scores were obtained from weight loss, exhaustion, gait speed, and grip strength. A total Disability Index (DI) expressed dependency for basic (b-), instrumental (i-), and advanced (a-)ADLs. Mediation was investigated by estimating direct and indirect effects of all levels of ADLs and CD-RISC total score on prefrailty/robustness using a stepwise multiple regression approach.

RESULTS

Prefrailty/robustness significantly correlated with a-ADL-DI (point-biserial correlation (rpb) = 0.098; p<0.05). Adjusted for age and gender, the a-ADL-DI (p<0.05) had a significant protective direct effect against prefrailty. No effects were found with the CD-RISC total score.

CONCLUSIONS

Less limitation in a-ADLs is a directly correlated factor of prefrailty and might represent a higher likelihood of robustness.

Frailty Does Not Impact Caregiver Burden in Patients with Cirrhosis

BACKGROUND

Frailty is common and is associated with increased mortality, lower quality of life, and higher readmission rates in cirrhotic patients. Not only are these outcomes important, but further understanding the impact of frailty on a caregiver's life is crucial to better comprehend caregiver burden in cirrhotic patients and develop strategies to improve care for patients and their caregivers.

METHODS

A single-center, prospective study was conducted of cirrhotic patients and their caregivers between 4/1/2019 and 11/1/2019. Frailty testing combined aspects from the Fried Frailty Instrument, Short Physical Performance Battery, and activities of daily living. Caregivers completed questionnaires to evaluate caregiver burden using the Zarit Burden Interview (ZBI-12), and perceived social support, using the Interpersonal Support Evaluation List.

RESULTS

In total, 94 cirrhotic patients were included, 50% males with a median age of 63.1 years. The most common etiology of cirrhosis was nonalcoholic steatohepatitis. Frailty was prevalent (45.1%). In total, 12.8% of caregivers reported a high burden based on ZBI-12. There was no association between frailty and caregiver burden, hospitalization rates, or death. However, frailty was associated with a higher number of outpatient GI visits (p = 0.002). Lower perceived social support among caregivers was associated with a higher caregiver burden (p < 0.0001).

CONCLUSION

Frailty is prevalent in cirrhotic patients but is not associated with higher rates of caregiver burden. Low perceived social support among caregivers, however, was associated with higher caregiver burden. It is important to recognize the impact of caregiver burden on caregivers of cirrhotic patients and ensure caregivers have the appropriate support to mitigate burden.

Perioperative frailty: lessons learned and future directions

PURPOSE OF REVIEW

As the surgical population ages, preoperative diagnosis and optimization of frailty becomes increasingly important. Various concepts are used to define frailty, and several tools have been validated for use in the perioperative period. This article reviews current conceptual frameworks of frailty, references current literature and provides a practical approach to the preoperative frailty assessment with a focus on potential interventions.

RECENT FINDINGS

A multipronged approach toward preoperative optimization should be used in patients with frailty syndrome. Oral protein supplementation and immunonutrition therapy can reduce complications in patients with malnutrition. Initiating a preoperative physical exercise regimen may mitigate frailty. Nonpharmacologic interventions to reduce preoperative anxiety and improve mood are effective, low-cost adjuncts associated with improvement in postoperative outcomes. Engaging in shared decision making is a critical component of the preoperative evaluation of frail patients.

SUMMARY

Emerging evidence suggests that frailty may be mitigated with patient-specific, multidimensional preoperative interventions, thus potentially improving postoperative outcomes in this vulnerable patient population.

Sarcopenia and Frailty in Liver Cirrhosis

Skeletal muscle is the largest organ in the body, and skeletal muscle atrophy results from a shift in the balance of protein synthesis and degradation toward protein breakdown. Primary sarcopenia is defined as a loss of skeletal muscle mass and strength or physical function due to aging, and secondary sarcopenia is defined as a loss of skeletal muscle mass and strength or physical function due to underlying diseases. Liver cirrhosis (LC) is one of the representative diseases which can be complicated with secondary sarcopenia. Muscle mass loss becomes more pronounced with worsening liver reserve in LC patients. While frailty encompasses a state of increased vulnerability to environmental factors, there is also the reversibility of returning to a healthy state with appropriate intervention. Several assessment criteria for sarcopenia and frailty were proposed in recent years. In 2016, the Japan Society of Hepatology created assessment criteria for sarcopenia in liver disease. In Japan, health checkups for frailty in the elderly aged 75 years or more started in April 2020. Both sarcopenia and frailty can be adverse predictors for cirrhotic patients. In this review article, we will summarize the current knowledge of sarcopenia and frailty in LC patients.

Dispositional Optimism and Context Sensitivity: Psychological Contributors to Frailty Status Among Elderly Outpatients

The association of resilience-related factors with frailty is a recent research topic. Dispositional optimism and context sensitivity are two psychological factors that differently contribute to individual resilience. This study aimed at investigating whether dispositional optimism and context sensitivity might contribute to a multifactorial model of frailty, together with established relevant factors such as cognitive and physical factors. This cross-sectional study involved 141 elderly outpatients (42 males and 99 females) aged ≥65 years, who were referred to the Geriatrics and Multidimensional Evaluation Clinic of the University Hospital of Messina. We used the following measures: the Mini-Mental State Examination (MMSE) to screen for global cognitive functioning; 4-m gait speed and handgrip strength to measure physical performance; a 35-item Frailty Index (FI) to evaluate patients’ frailty status; the revised Life Orientation Test (LOT-R) to gauge dispositional optimism; and the Context Sensitivity Index (CSI) to measure context sensitivity. We found that LOT-R (β = −0.190, p = 0.038), CSI (β = −0.191, p = 0.035), and MMSE (β = −0.466, p < 0.001) were all significantly associated with FI. Gait speed was only marginally associated with FI (β = −0.184, p = 0.053). The present study showed a novel association of dispositional optimism and context sensitivity with frailty among elderly outpatients. These preliminary findings support a multidimensional approach to frailty in which even peculiar psychological features might provide a significant contribution.