Chapter 1 Frailty: Definition, diagnosis, epidemiology

Research Progress on Frailty in Elderly People

Global aging is rapidly accelerating, which significantly influences the health systems worldwide. Frailty emerges as the most conspicuous hallmark of aging, imposing novel global health challenges. Characterized by a multifaceted decline across physiological system, frailty diminishes an individual's capacity to maintain equilibrium in the presence of stressors, which leads to adverse outcomes such as falls, delirium, and disability. Several screening tools and interventions have been developed to mitigate the harm caused by frailty to human health, but research on frailty in mainland China commences belatedly with scant studies conducted. Therefore, it is imperative to explore screening methods and treatment modalities tailored to the Chinese context, thereby enhancing the older adults' quality of life and advancing social medicine. This review aims to elucidate the evolution, diagnosis, and management of frailty, alongside the challenges it poses, with the overarching goal of guiding future diagnostic and therapeutic endeavors. Specifically, we summarized the mechanisms of frailty and intervention strategies in elderly people, and meanwhile, we evaluated the advantages and disadvantages of different measurement tools.

A Novel Method for Identifying Frailty and Quantifying Muscle Strength Using the Six-Minute Walking Test

The six-minute walking test (6MWT) is an essential test for evaluating exercise tolerance in many respiratory and cardiovascular diseases. Frailty and sarcopenia can cause rapid aging of the cardiovascular system in elderly people. Early detection and evaluation of frailty and sarcopenia are crucial for determining the treatment method. We aimed to develop a wearable measuring system for the 6MWT and propose a method for identifying frailty and quantifying walking muscle strength (WMS). In this study, 60 elderly participants were asked to wear accelerometers behind their left and right ankles during the 6MWT. The gait data were collected by a computer or smartphone. We proposed a method for analyzing walking performance using the stride length (SL) and step cadence (SC) instead of gait speed directly. Four regions (Range I-IV) were divided by cutoff values of SC = 2.0 [step/s] and SL = 0.6 [m/step] for a quick view of the frail state. There were 62.5% of frail individuals distributed in Range III and 72.4% of non-frail individuals in Range I. A concept of a WMS score was proposed for estimating WMS quantitatively. We found that 62.5% of frail individuals were scored as WMS1 and 41.4% of the non-frail elderly as WMS4. The average walking distances corresponding to WMS1-4 were 207 m, 370 m, 432 m, and 462 m, respectively. The WMS score may be a useful tool for quantitatively estimating sarcopenia or frailty due to reduced cardiopulmonary function.

Nutritional and inflammation factors associated with current frailty level and effect of co-morbidities on the progression of frailty

AIM

Frailty is defined as extreme vulnerability, a syndrome that exposes the individual to a higher risk of disability. While risk factors for frailty have been gradually uncovered, the full identification of biochemical factors and co-morbidities influencing frailty remains incomplete.

METHODS

Cross-sectional and longitudinal analyses were performed to elucidate the risk factors for the prevalence and progression of frailty. The study included 1035 Japanese female outpatients. At baseline, biochemical markers were measured. Co-morbidities included diabetes mellitus, dyslipidemia, hypertension, vertebral osteoarthritis, and osteoporosis. Frailty levels were assessed using frailty scores ranging from 0 to 5. Prevalence of frailty was judged by a score of 3 or above, and progression was judged by an increase in the frailty score during the observation period. Multiple regression analysis was used for the cross-sectional analysis, and the Cox hazard model was used for the longitudinal analysis.

RESULTS

Of the 1035 selected participants, 212 were diagnosed with frailty. Advanced age and log IL-6 and branched-chain amino acids (BCAA) levels were significant independent risk factors for frailty. Subjects were followed for 7.7 ± 5.9 years and progression was observed in 130 subjects. Older age, the absence of hyperlipidemia, the presence of osteoporosis, and lower frailty scores were identified as significant risk factors for frailty progression.

CONCLUSIONS

Inflammatory and nutritional markers exhibited significant associations with the current frailty status, whereas co-morbidities such as osteoporosis or hyperlipidemia emerged as independent risk or protective factors of future frailty progression. Geriatr Gerontol Int 2024; 24: 523-528.

Prevalence and associated factors of locomotive syndrome in young Japanese adults: a cross-sectional study

BACKGROUND

The onset of locomotive syndrome (LS) precedes that of frailty. Therefore, the first step in extending healthy life expectancy is to implement measures against LS in young adults. The aim of this study was to investigate the prevalence of LS and its associated factors in young adults for early detection and prevention of LS.

METHODS

The participants of this study comprised 413 university students specializing in health sciences (192 males and 221 females) with an average age of 19.1 ± 1.2 years. All participants voluntarily participated in the study and reported no serious health problems. The presence or absence of LS was evaluated using the stand-up test, two-step test, and the 25-question Geriatric Locomotive Function Scale. Additionally, musculoskeletal assessment (one-leg standing, squatting, shoulder elevation, and standing forward bend), body composition analysis (weight, body mass index, body fat mass, body fat percentage, skeletal muscle mass index (SMI), and phase angle), handgrip strength test, physical activity assessment, and nutritional assessment were conducted. Sex-stratified analyses were performed, comparing groups with and without LS. Factors associated with LS were explored using binomial logistic regression.

RESULTS

Of the 413 young adults studied, 86 individuals (20.8%) were found to have LS. When stratified by sex, LS was observed to have a considerably higher prevalence in females (55, 24.9%) than in males (31, 16.1%). In males, the notable differences between the groups with and without LS were observed in one-leg standing and phase angle, whereas in females, differences were identified in body fat mass, body fat percentage, SMI, musculoskeletal pain, and handgrip strength. Two types of binomial logistic regression analysis revealed that the inability to perform one-leg standing was associated with LS in males, while the presence of musculoskeletal pain and a high body fat percentage were identified as factors associated with LS in females.

CONCLUSIONS

One in five young adults were found to have LS in this study, underscoring the necessity for early intervention and LS health education. Furthermore, effective management of musculoskeletal pain is also crucial.

Do the physical activity questions in the Japanese version of the Cardiovascular Health Study criteria truly reflect a decline in physical activity?

Older participants identified as having decreased physical activity according to the Japanese version of the Cardiovascular Health Study criteria did not show a significant reduction in accelerometer-measured physical activity. Despite its widespread use in Japanese studies, the Japanese version of the Cardiovascular Health Study physical activity questionnaire may not effectively capture declines in physical activity.

Impact of frailty on long-term outcomes after liver resection for hepatocellular carcinoma in elderly patients: A prospective study

BACKGROUND

sFrailty affects short-term outcomes after liver resection in elderly patients. However, frailty's effects on long-term outcomes after liver resection in elderly patients with hepatocellular carcinoma (HCC) are unknown.

METHODS

This prospective, single-center study included 81 independently living patients aged ≥65 years scheduled to undergo liver resection for initial HCC. Frailty was evaluated according to the Kihon Checklist, a phenotypic frailty index." We investigated and compared postoperative long-term outcomes after liver resection between patients with and without frailty.

RESULTS

Of the 81 patients, 25 (30.9%) were frail. The proportion of patients with cirrhosis, high serum alpha-fetoprotein level (≥200 ng/mL), and poorly differentiated HCC was higher in the frail group than in the nonfrail group (n = 56). Among the patients with postoperative recurrence, the incidence of extrahepatic recurrence was higher in the frail group than in the nonfrail group (30.8% vs. 3.6%, P = 0.028). Moreover, the proportion of patients who underwent repeat liver resection and ablation for recurrence who met the Milan criteria tended to be lower in the frail group than in the nonfrail group. Although there was no difference in disease-free survival between the two groups, the overall survival rate in the frail group was significantly worse than that in the nonfrail group (5-year overall survival: 42.7% vs. 77.2%, P = 0.005). Results of the multivariate analysis indicated that frailty and blood loss were independent prognostic factors for postoperative survival.

CONCLUSION

Frailty is associated with unfavorable long-term outcomes after liver resection in elderly patients with HCC.

Network analysis of frailty indicators in hospitalized elderly patients: unveiling the role of depression and hemoglobin as core factors

BACKGROUND

Frailty is a significant concern among hospitalized older adults, influenced by multiple factors. Understanding the complex interactions between these variables can be facilitated through a network perspective.

AIM

This study aimed to identify the core factor and physiological indicator of frailty in hospitalized elderly patients and visualize their interactions within the network structure.

METHODS

Frailty was assessed using the Tilburg Frailty Indicators, with a score of 5 or higher indicating frailty. Additional variables related to sociodemographic, physical and clinical, psychological and cognitive aspects, as well as physiological indicators, were extracted from electronic health records. A partial correlation network analysis was conducted using an adaptive LASSO algorithm, based on univariate correlation and logistic regression, to examine the network structure and identify influential nodes.

RESULTS

The average age of participants was 70.74 ± 7.52 years, with 24.27% classified as frail. Frailty was associated with 38 of 145 initially included variables (P < 0.05). The network analysis revealed depression as the most central node, followed by drugs used, sleep disorders, loneliness, masticatory obstacles, drinking, and number of teeth missing. Hemoglobin emerged as the most central biochemical indicator in the network, based on network center index analysis (Strength = 4.858, Betweenness = 223, Closeness = 0.034).

CONCLUSIONS

Frailty in hospitalized older adults is influenced by various social, physical, and psychological factors, with depression as the core factor of utmost importance. Changes in hemoglobin levels could serve as an essential indicator. This innovative network approach provides insights into the multidimensional structure and relationships in real-world settings.

Establishment and evaluation of a novel practical tool for the diagnosis of pre-sarcopenia in young people with diabetes mellitus

OBJECTIVE

Sarcopenia has been recognized as a third category of complications in people with diabetes. However, few studies focus on the reduction of skeletal muscle mass in young people with diabetes. The aim of this study was to investigate risk factors of pre-sarcopenia in young patients with diabetes and establish a practical tool to diagnose pre-sarcopenia in those people.

METHODS

Patients (n = 1246) enrolled from the National Health and Nutrition Examination Survey (NHANES) cycle year of 2011 to 2018 were randomly divided into the training set and validation set. The all-subsets regression analysis was used to select the risk factors of pre-sarcopenia. A nomogram model for the prediction of pre-sarcopenia in the diabetic population was established based on the risk factors. The model was evaluated by the area under the receiver operating characteristic curve for discrimination, calibration curves for calibration, and decision curve analysis curves for clinical utility.

RESULTS

In this study, gender, height, and waist circumference were elected as predictive factors for pre-sarcopenia. The nomogram model presented excellent discrimination in training and validation sets with areas under the curve of 0.907 and 0.912, respectively. The calibration curve illustrated excellent calibration, and the decision curve analysis showed a wide range of good clinical utility.

CONCLUSIONS

This study develops a novel nomogram that integrates gender, height, and waist circumference and can be used to easily predict pre-sarcopenia in diabetics. The novel screen tool is accurate, specific, and low-cost, highlighting its potential value in clinical application.

Higher Hospital Frailty Risk Score Is Associated With Increased Risk of Stroke: Observational and Genetic Analyses

BACKGROUND

Frailty is a prevalent state associated with several aging-related traits and conditions. The relationship between frailty and stroke remains understudied. Here we aim to investigate whether the hospital frailty risk score (HFRS) is associated with the risk of stroke and determine whether a significant association between genetically determined frailty and stroke exists.

DESIGN

Observational study using data from All of Us research program and Mendelian Randomization analyses.

METHODS

Participants from All of Us with available electronic health records were selected for analysis. All of Us began national enrollment in 2018 and is expected to continue for at least 10 years. All of Us is recruiting members of groups that have traditionally been underrepresented in research. All participants provided informed consent at the time of enrollment, and the date of consent was recorded for each participant. Incident stroke was defined as stroke event happening on or after the date of consent to the All of Us study HFRS was measured with a 3-year look-back period before the date of consent for stroke risk. The HFRS was stratified into 4 categories: no-frailty (HFRS=0), low (HFRS ≥1 and <5), intermediate (≥5 and <15), and high (HFRS ≥15). Last, we implemented Mendelian Randomization analyses to evaluate whether genetically determined frailty is associated with stroke risk.

RESULTS

Two hundred fifty-three thousand two hundred twenty-six participants were at risk of stroke. In multivariable analyses, frailty status was significantly associated with risk of any (ischemic or hemorrhagic) stroke following a dose-response way: not-frail versus low HFRS (HR, 4.9 [CI, 3.5-6.8]; P<0.001), not-frail versus intermediate HFRS (HR, 11.4 [CI, 8.3-15.7]; P<0.001) and not-frail versus high HFRS (HR, 42.8 [CI, 31.2-58.6]; P<0.001). We found similar associations when evaluating ischemic and hemorrhagic stroke separately (P value for all comparisons <0.05). Mendelian Randomization confirmed this association by indicating that genetically determined frailty was independently associated with risk of any stroke (OR, 1.45 [95% CI, 1.15-1.84]; P=0.002).

CONCLUSIONS

Frailty, based on the HFRS was associated with higher risk of any stroke. Mendelian Randomization analyses confirmed this association providing evidence to support a causal relationship.

Prognostic Impact of Baseline Six-Minute Walk Distance following Trans-Catheter Aortic Valve Replacement

BACKGROUND

The six-minute walk test is a practical tool for assessing functional capacity in patients with a variety of etiologies including pulmonary disease and heart failure. Six-minute walk distance (6MWD) is associated with mortality and morbidity in patients with a variety of comorbidities. We aimed to assess the prognostic impact of baseline 6MWD in patients with severe aortic stenosis undergoing trans-catheter aortic valve replacement (TAVR).

METHODS

Patients with severe aortic stenosis who underwent a six-minute walk test after index admission and underwent TAVR between 2015 and 2022 were included in this retrospective study. Patients were followed up for two years or until November 2022 following TAVR. The impact of baseline 6MWD on the primary composite outcome, defined as all-cause death and all-cause readmission during the 2-year observation period following index discharge, was assessed.

RESULTS

A total of 299 patients (median age 86 years old, 85 men) were included. They received a 6-min walk test prior to TAVR, underwent successful TAVR procedures, and were discharged alive. The median baseline 6MWD was 204 (143, 282) meters. Shorter baseline 6MWD was associated with higher cumulative incidence of the primary outcome with an adjusted hazard ratio of 0.76 (95% confidence interval 0.58-1.01, p = 0.055) with a cutoff 6MWD of 178 m during the 2-year observation period after index discharge.

CONCLUSIONS

Overall, functional capacity was impaired in the elderly patients with severe aortic stenosis prior to TAVR. Patients with severe aortic stenosis having shorter baseline 6MWD tended to have higher rates of morbidity and mortality after successful TAVR. The clinical implication of aggressive cardiac rehabilitation to improve patients' functional capacity and 6MWD-guided optimal patient selection remain the future concerns.

Hospital Frailty Risk Score Predicts Adverse Events and Readmission Following a Ventriculoperitoneal Shunt Surgery for Normal Pressure Hydrocephalus

OBJECTIVE

The aim of this study was to evaluate the impact of a Hospital Frailty Risk Score (HFRS) on unplanned readmission and health care resource utilization in normal pressure hydrocephalus (NPH) patients undergoing a ventriculoperitoneal (VP) shunt surgery.

METHODS

A retrospective cohort study was performed using the 2016-2019 Nationwide Readmission Database. All NPH patients (≥60 years) undergoing a VP shunt surgery were identified using ICD-10-CM diagnostic and procedural codes. Patients were dichotomized into 2 cohorts as follows: Low HFRS (<5) and Intermediate-High HFRS (≥5). A multivariate logistic regression analysis was then used to identify independent predictors of adverse event (AE) and 30- and 90-day readmission.

RESULTS

Of 13,262 patients, 4386 (33.1%) had an Intermediate-High HFRS score. A greater proportion of the Intermediate-High HFRS cohort experienced at least one AE (1.9 vs. 22.1, P < 0.001). The Intermediate-High HFRS cohort also had a longer length of stay (2.3 ± 2.4 days vs. 7.0 ± 7.7 days, P < 0.001), higher non-routine discharge rate (19.9% vs. 39.9%, P < 0.001), and greater admission cost ($14,634 ± 5703 vs. $21,749 ± 15,234, P < 0.001). The Intermediate-High HFRS cohort had higher rates of 30- (7.6% vs. 11.0%, P < 0.001) and 90-day (6.8% vs. 8.3%, P < 0.001) readmissions. On a multivariate regression analysis, Intermediate-High HFRS compared to Low HFRS was an independent predictor of any AE (odds ratio, 16.6; 95% confidence interval, [12.9-21.5]; P < 0.001) and 30-day readmission (odds ratio, 1.4; 95% confidence interval, [1.2-1.7]; P < 0.001).

CONCLUSIONS

Our study suggests that frailty, as defined by HFRS, is associated with increased resource utilization in NPH patients undergoing VP shunt surgery. Furthermore, HFRS was an independent predictor of adverse events and 30-day hospital readmission.

Cross-cultural Adaptation of Oral and Maxillofacial Frailty Assessment Tools for Geriatric Population of Kerala

AIM

The aim of this study is to translate the oral and maxillofacial frailty index (OMFI) into Malayalam, culturally adapt it, and test its reliability and validity in the Kerala geriatric population.

MATERIALS AND METHODS

OMFI was translated, culturally adapted, and validated in Malayalam using a methodological and cross-sectional study design. The Malayalam version of OMFI underwent full linguistic validation and was tested on 200 patients at Amritakripa Hospital in Kalpetta. Principal component analysis with varimax rotation was used for exploratory factor analysis, and Cronbach's alpha was used to assess reliability.

RESULTS

Two-hundred patients were recruited in this study. Participants ranged in age from 60 to 83 years; mean age was 68 years (SD: 15.21). In total 55.5% were male participants, and 30.5% were belonging to upper middle class as per the Kuppuswami scale. Only 12% of the participants were living alone. Kaiser-Meyer-Olkin was found to be 0.583, and Bartlett's test of sphericity was significant with a Chi-square test value of 1003.469. A principal axis factor analysis conducted on 20 items with orthogonal rotation (varimax). OMFI Malayalam version (5 items) had a good internal consistency (Cronbach's alpha = 0.751). Item-total correlations were reviewed for the items of OMFI.

CONCLUSION

The OMFI Malayalam version demonstrated acceptable validity and reliability and can be used to screen the oral frailty of the geriatric population in Kerala.

CLINICAL SIGNIFICANCE

As Kerala is having highest geriatric population in India, we need to assess the oral frailty burden of Kerala. This study provided the first measure to assess the oral frailty in elderly in Kerala.

Frailty under COVID-19 pandemic in Japan: Changes in prevalence of frailty from 2017 to 2021

BACKGROUND

After the outbreak of the coronavirus disease 2019 (COVID-19), "pandemic-associated-frailty" or profound health deterioration, in older adults has been considered a health concern. In this study, we sought to demonstrate whether pandemic-associated-frailty is occurring in Japan, where the population is aging, by showing the prevalence of frailty before and during the COVID-19 outbreak, using the same method.

METHODS

A total of 5222 older adults in Otawara City, Tochigi Prefecture, aged 70 and 75 were surveyed annually using a complete survey, excluding those who were certified as requiring long-term care. Frailty during 2017-2019 before the COVID-19 outbreak and during 2020-2021 during the COVID-19 outbreak was determined using the Kihon Checklist (KCL). Statistical analysis was performed using the χ² test to compare annual frailty status and Kruskal-Wallis test to compare the scores.

RESULTS

The frailty statuses over the five-year period showed a significant decrease in Robust and a significant increase in Pre-frailty and Frailty (p < 0.001). Frailty increased markedly during the second year of the pandemic. Based on the category, the scores deteriorated significantly for activities of daily living (p < 0.001), physical function (p = 0.003), oral function (p < 0.001), outdoor activity (p < 0.001), and depression (p < 0.001). Moreover, there was a significant deterioration in the total score for 25 items (p < 0.001). In addition, a significant deterioration was observed in the total score of 23 items, excluding the social withdrawal affected by self-restraint life (p < 0.001).

CONCLUSIONS

The population prevalence of frailty in older adults increased steadily from the pre-pandemic year through the first and second years of the pandemic. Based on the 25 questions of the KCL, two aspects including visiting friends and going out less stood out. This suggests that pandemic-associated-frailty occurred in Japan.

Frailty and cognitive impairment in Parkinson’s disease: a systematic review

BACKGROUND

Frailty can lead to increased vulnerability in older people and patients with Parkinson's disease (pwPD) and worsen their health conditions. These patients can also develop cognitive function impairment. The objective is to analyze whether there is a relationship between frailty and cognitive impairment in pwPD, and to find out which instruments to use for its evaluation.

METHODS

Publications were searched in PubMed, Medline, Web of Science, Cinalh, Cochrane Library, Embase, Phycinfo, and Scopus. The results were measured with the instruments that are used to assess frailty and cognitive impairment, and analyze their relationship.

RESULTS

Two hundred seventy-one articles were identified, of which 12 met the inclusion criteria. All studies assessed frailty and cognitive function in pwPD. Five studies analyzed the relationship between frailty and cognitive impairment. The most used instruments were the Fried scale followed by the Clinical Frailty Scale (CFS) for frailty. Cognitive impairment was mostly evaluated with the Mini-Mental State Examination and the Montreal Cognitive Assessment. The prevalence data ranged from 20.2 to 51.5% with the Fried scale and from 35.6 to 83.9% with the CFS. Cognitive impairment was present in 15 to 45.2% of the pwPD.

CONCLUSION

Analysis of the included studies shows a relationship between frailty and cognitive impairment in pwPD. There was significant variability in the application of the scales used, which influences the prevalence data. More observational and experimental studies are needed to provide more evidence on this association and to determine which is the optimal tool to identify frailty in pwPD using multidimensional scales.

Kihon Checklist items associated with the development of frailty and recovery to robust status during the COVID-19 pandemic

AIM

The Kihon Checklist (KCL) is used to assess frailty in daily life. We aimed to identify KCL items associated with the development of frailty and recovery to robust status during the COVID-19 pandemic.

METHODS

We conducted a 1-year prospective cohort study of community-dwelling adults aged 70 and 75 years in Otawara City, Tochigi Prefecture, Japan. Information regarding age, sex, presence of disease and KCL items was collected in May 2020 (baseline) and June 2021 (follow-up) using a mailed questionnaire. Changes in frailty status as determined by the KCL at baseline and follow-up were evaluated. To clarify factors related to changes in the frailty status, we conducted two sets of binomial logistic regression analyses with the presence/absence of development of frailty and presence/absence of recovery to robust status at follow-up as the dependent variables and the KCL items as the independent variables.

RESULTS

The analysis included 716 participants who provided complete responses to both questionnaires. The KCL Items 6, 10, 20, 23 and 24 were related to the development of frailty, and the KCL Items 6, 15, 21 and 23 were associated with the recovery to robust status.

CONCLUSIONS

The baseline KCL items regarding physical function and associated mental aspects were related to both development of frailty and recovery to robust status during the COVID-19 pandemic. Cognitive and depressive declines were associated with the development of frailty, while good oral environment and sense of fulfillment in life were associated with the recovery to robust status. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2022; ••: ••-••.

Osteosarcopenia, the co-existence of osteoporosis and sarcopenia, is associated with social frailty in older adults

BACKGROUND

Osteosarcopenia is a newly described, aging-associated condition. Social frailty is an important condition whose prevalence may have risen by physical distancing during the coronavirus disease 2019 pandemic. However, the relationship between these two remains unclear.

AIMS

To examine the association between osteosarcopenia and social frailty.

METHODS

This cross-sectional study was conducted using data from outpatients visiting general geriatric hospital frailty clinics. Bone mineral density (BMD) and muscle mass were measured using dual X-ray absorptiometry. Osteoporosis was defined as a BMD of < 70% of the young adult mean, according to the Japan Osteoporosis Society. Sarcopenia was diagnosed as per the Asian Working Group for Sarcopenia 2019 recommendation. Osteosarcopenia was defined as the co-existence of osteoporosis and sarcopenia. We defined social frailty using a questionnaire comprising four items: general resources, social resources, social behavior, and basic social needs. Ordinal logistic regression analysis was performed with social frailty status and osteosarcopenia as the dependent and independent variables, respectively.

RESULTS

We included 495 patients (mean age = 76.5 ± 7.2 years) in the analysis; of these, 58.2% were robust and 17.2%, 13.5%, and 11.1% had osteoporosis alone, sarcopenia alone, and osteosarcopenia, respectively. Social frailty prevalence increased stepwise from 8.0% in robust patients to 11.8%, 17.9%, and 29.1% among those with osteoporosis alone, sarcopenia alone, and osteosarcopenia, respectively (P < 0.001). Logistic regression analysis revealed that only osteosarcopenia was significantly associated with social frailty (pooled odds ratio: 2.117; 95% confidence interval: 1.104-4.213).

DISCUSSION

Comprehensive assessment of osteosarcopenia and social frailty is needed for disability prevention in older adults.

Prevalence and prognostic impact of cognitive frailty in elderly patients with heart failure: sub-analysis of FRAGILE-HF

Aims

Although evidence suggests that cognitive decline and physical frailty in elderly patients with heart failure (HF) are associated with prognosis, the impact of concurrent physical frailty and cognitive impairment, that is, cognitive frailty, on prognosis has yet to be fully investigated. The current study sought to investigate the prevalence and prognostic impact of cognitive frailty in elderly patients with HF.

Methods and results

This study is a sub‐analysis of FRAGILE‐HF, a prospective multicentre observational study involving patients aged ≥65 years hospitalized for HF. The Fried criteria and Mini‐Cog were used to diagnose physical frailty and cognitive impairment, respectively. The association between cognitive frailty and the combined endpoint of mortality and HF rehospitalization within 1 year was then evaluated. Among the 1332 patients identified, 1215 who could be assessed using Mini‐Cog and the Fried criteria were included in this study. Among those included, 279 patients (23.0%) had cognitive frailty. During the follow‐up 1 year after discharge, 398 combined events were observed. Moreover, cognitive frailty was determined to be associated with a higher incidence of combined events (log‐rank: P = 0.0146). This association was retained even after adjusting for other prognostic factors (hazard ratio: 1.55, 95% confidence interval: 1.13–2.13). Furthermore, a sensitivity analysis using grip strength, short physical performance battery, and gait speed to determine physical frailty instead of the Fried criteria showed similar results.

Conclusions

This cohort study found that 23% of elderly patients with HF had cognitive frailty, which was associated with a 1.55‐fold greater risk for combined events within 1 year compared with patients without cognitive frailty.

Frailty and risk of hospitalization from COVID-19 infection among older adults: evidence from the Dutch Lifelines COVID-19 Cohort study

BACKGROUND

Frailty is associated with COVID-19 severity in clinical settings. No general population-based studies on the association between actual frailty status and COVID-19 hospitalization are available.

AIMS

To investigate the association between frailty and the risk of COVID-19 hospitalization once infected.

METHODS

440 older adults who participated in the Lifelines COVID-19 Cohort study in the Northern Netherlands and reported positive COVID-19 testing results (54.2% women, age 70 ± 4 years in 2021) were included in the analyses. COVID-19 hospitalization status was self-reported. The Groningen Frailty Indicator (GFI) was derived from 15 self-reported questionnaire items related to daily activities, health problems, and psychosocial functioning, with a score ≥ 4 indicating frailty. Both frailty and COVID-19 hospitalization were assessed in the same period. Poisson regression models with robust standard errors were used to analyze the associations between frailty and COVID-19 hospitalization.

RESULTS

Of 440 older adults included, 42 were hospitalized because of COVID-19 infection. After adjusting for sociodemographic and lifestyle factors, a higher risk of COVID-19 hospitalization was observed for frail individuals (risk ratio (RR) [95% CI] 1.97 [1.06-3.67]) compared to those classified as non-frail.

DISCUSSION

Frailty was positively associated with COVID-19 hospitalization once infected, independent of sociodemographic and lifestyle factors. Future research on frailty and COVID-19 should consider biomarkers of aging and frailty to understand the pathophysiological mechanisms and manifestations between frailty and COVID-19 outcomes.

CONCLUSIONS

Frailty was positively associated with the risk of hospitalization among older adults that were infected with COVID-19. Public health strategies for frailty prevention in older adults need to be advocated, as it is helpful to reduce the burden of the healthcare system, particularly during a pandemic like COVID-19.

Association between Poor Oral Health and Frailty in Middle-Aged and Older Individuals: A Cross-Sectional National Study

OBJECTIVES

Older adults with poor oral health may be at higher risk of being pre-frail or frail. However, very few studies have examined this association in Latin American countries and middle-aged individuals. Therefore, we aimed to investigate the association between oral health and frailty status among Chilean adults ≥40 years.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

We included 3,036 participants ≥40 years from the Chilean National Health Survey 2016-2017.

METHODS

Frailty status was assessed with a 49-item frailty index, while the number of teeth, self-reported oral health, tooth decay, use of prostheses, and oral pain were the oral health conditions included. To assess the association between oral health conditions and frailty, we used multinomial logistic regression models status adjusted for sociodemographic and lifestyle variables.

RESULTS

Overall, 40.6% and 11.8% of individuals were classified as pre-frail and frail, respectively. After adjusting for confounders, individuals with ≤20 teeth had a higher likelihood of being frail (odds ratio (OR): 1.94 [95% CI: 1.18-3.20]) than people with >20 teeth. Moreover, people with bad or very bad oral health, as well as oral pain, had a higher likelihood of being pre-frail (OR: 2.04 [95% CI: 1.40-2.97] and OR: 2.92 [95% CI: 1.58-5.39], respectively). Middle-aged individuals with fewer teeth and poor self-reported oral health had a higher likelihood of being pre-frail and frail than people ≥60.

CONCLUSIONS AND IMPLICATIONS

Individuals with poor global oral health were more likely to be pre-frail or frail. This association seems to be stronger in people <60 years old. Our results are consistent with previously published reports.

Multidimensional prognostic index and the risk of fractures: an 8-year longitudinal cohort study in the Osteoarthritis Initiative

In this longitudinal study, with a follow-up of 8 years, multidimensional prognostic index (MPI), a product of the comprehensive geriatric assessment, significantly predicted the onset of fractures in older people affected by knee osteoarthritis.

PURPOSE

Frailty may be associated with higher fracture risk, but limited research has been carried out using a multidimensional approach to frailty assessment and diagnosis. The present research aimed to investigate whether the MPI, based on comprehensive geriatric assessment (CGA), is associated with the risk of fractures in the Osteoarthritis Initiative (OAI) study.

METHODS

Community-dwellers affected by knee OA or at high risk for this condition were followed-up for 8 years. A standardized CGA including information on functional, nutritional, mood, comorbidity, medication, quality of life, and co-habitation status was used to calculate the MPI. Fractures were diagnosed using self-reported information. Cox's regression analysis was carried out and results are reported as hazard ratios (HRs), with their 95% confidence intervals (CIs), adjusted for potential confounders.

RESULTS

The sample consisted of 4024 individuals (mean age 61.0 years, females = 59.0%). People with incident fractures had a significant higher MPI baseline value than those without (0.42 ± 0.18 vs. 0.40 ± 0.17). After adjusting for several potential confounders, people with an MPI over 0.66 (HR = 1.49; 95%CI: 1.11-2.00) experienced a higher risk of fractures. An increase in 0.10 point in MPI score corresponded to an increase in fracture risk of 4% (HR = 1.04; 95%CI: 1.008-1.07). Higher MPI values were also associated with a higher risk of non-vertebral clinical fractures.

CONCLUSION

Higher MPI values at baseline were associated with an increased risk of fractures, reinforcing the importance of CGA in predicting fractures in older people affected by knee OA.

A Cross-Sectional Study on the Characteristics of Physical Activity in Pre-Frail Older Adults

This cross-sectional study aimed to characterize the physical activity (PA) of older adults with pre-frail status by examining sedentary behavior (SB) and PA using triaxial accelerometer data, with non-frail older adults as the control group. In this study, we divided the study participants into older adults who regularly participated in self-initiated citizen group exercise activities and those who did not. Data were collected between September and December 2017. We analyzed data from 256 older adults (women: 86.3%) aged ≥65 years. The interaction effect of participation status (participation and non-participation group) and frailty status (pre-frail and non-frail group) for moderate-to-vigorous PA (F = 9.178, p = 0.003) and daily mean number of steps (F = 9.351, p = 0.002) was significant. For the participation group, there was no difference between pre-frail older adults and non-frail older adults regarding length of SB and PA time, indicating that PA level was maintained in the participating pre-frail older adults. In contrast, moderate-to-vigorous PA and daily mean number of steps were low in pre-frail older adults who did not participate in the activities. The opportunity to participate in self-initiated group exercise activities and other PAs in the community may help pre-frail older adults maintain their PA.

Protein Nutritional Status and Frailty: A Mendelian Randomization Study

BACKGROUND

Observational studies have suggested that better protein nutritional status may contribute to prevention of frailty.

OBJECTIVE

We sought to examine this hypothesis using a Mendelian randomization (MR) analysis.

METHODS

We conducted a two-sample MR study using GWAS summary statistics data of the UK Biobank. We applied genetically predicted serum albumin as a primary exposure measure and serum total protein as a secondary exposure measure. The outcome measure was the Rockwood frailty index (FI) based on 49 deficits from 356,432 individuals (53.3% of them were women, with a mean ± SD age of 56.7 ± 8.0 y. The association between serum protein measures and FI was mainly analyzed by use of the inverse variance weighted method.

RESULTS

A genetically predicted serum albumin concentration was not statistically significantly associated with FI in the full sample. However, in women, we observed a preventive association between genetically predicted serum albumin and FI (β = -0.172 per g/L; 95% CI: -0.336, -0.007; P = 0.041). In the full sample, genetically predicted serum total protein was inversely associated with FI (β: -0.153 per g/L; 95% CI: -0.251, -0.056; P = 0.002). In both women and men, higher serum total protein was significantly inversely associated with FI; regression coefficients were -0.148 per g/L (95% CI: -0.287, -0.009; P = 0.037) for women, -0.154 per g/L (95% CI: -0.290, -0.018; P = 0.027) for men.

CONCLUSIONS

The present MR study implies that better protein nutritional status modestly contributes to reducing the risk of frailty.

Nutritional status as a mediator between the age-related muscle loss and frailty in community-dwelling older adults

PURPOSE

The purposes of the study were: a) to investigate the prevalence of sarcopenia, obesity and sarcopenic obesity (SO) in older adults, b) to explore the effect of nutrition as mediator of the association between these entities and frailty.

MATERIALS AND METHODS

Older adults (≥65 years) were evaluated based on European Working Group on Sarcopenia in Older People criteria for the presence/absence of sarcopenia. Obesity was diagnosed by using Zoico methodology. FRAIL scale was used to evaluate frailty and nutritional status was assessed with Mini Nutritional Assessment (MNA).

RESULTS

Five-hundred-seventy individuals (68,9% female, mean age 74,41±6,57 years) were included. The prevalence of sarcopenia, obesity and SO were 18,6%, 28,9% and 11,2%, respectively. FRAIL scores were directly affected by having sarcopenia (β: 0.42, 95% CI: (0.21-0.67), p<0.001) and SO (β: 0.31, 95% CI: (0.06-0.59), p:0.015), whereas obesity had no direct effect on FRAIL (β: 0.1, 95% CI: (-0.08-0.3), p:0.26). MNA was a mediator (β: -0.35, 95% CI: (-0.12-(-0.08)), p<0.0001) in both sarcopenic (β: -0.69, 95% CI: (-3.34-(-1.69)), p<0.0001) and SO patients (β: -0.34, 95% CI: (-2.21-(-0.26)), p:0.013), but not in obese group (β: -0.01, 95% CI: (-0.08-0.04). After the Bonferroni corrections,only sarcopenia had an association with frailty with MNA being the mediator.

CONCLUSION

The findings revealed that the frailty rate was higher in sarcopenia (20,8%) and SO (17,2%) groups than obese (5,5%) group. Frailty was associated with sarcopenia and SO, but not with obesity. Nutritional status was found to be a mediator of the association between age-related muscle loss and frailty To the best of our knowledge, this is the first study to report the mediator of the associations between age-related muscle loss and frailty.

The Value of Insulin Degludec in Frail Older Adults with Type 2 Diabetes

Insulin represents a mainstay of glucose-lowering therapy for many adults with type 2 diabetes mellitus (T2DM). Insulin treatments prescribed as standard care for the majority of people with T2DM, such as basal human insulin, may not be optimal in the treatment of frail older adults because of the increased demand on health care staff to administer multiple daily injections and monitor the patient. When choosing an insulin regimen for a frail older person with T2DM, predictability of glucose lowering effect, risk of hypoglycaemia, ease of administration, and simplicity and flexibility of dosing are major determining factors. Multiple daily injections may be too complex for older frail adults, whilst providing an unnecessary degree of tight glycaemic control and low doses of once-daily basal insulin analogues such as insulin degludec may be a reasonable option as cognitive decline or functional disability increases. Although insulin degludec has a substantially higher acquisition cost than routinely used basal human insulin, it has a longer, more predictable pharmacological profile and is more amenable to once-daily administration, translating into a reduced burden of care and potential cost savings for insulin-treated frail older adults. Insulin acquisition cost represents only a small proportion of the total cost of treatment, and it is important to consider the value perspective of insulin therapy in frail older adults from all stakeholders in the health care system.

Plasma Levels of Interleukin-6 and the Cluster of Differentiation 4/Cluster of Differentiation 8 Ratio in Frailty among Community-dwelling Older People

Background: Frailty has become a major health problem among Indonesian elders. Immunosenescence specifically inflammaging are essential components in the development of frailty. Early screening and timely tailored intervention may effectively prevent or delay the adverse outcomes in elders. This study measured the CD4/CD8 ratio from the immunosenescence pathway and plasma IL-6 levels as inflammatory markers from the inflammaging pathway and observed the correlations between robust and frail elders groups Methods: We conducted a cross-sectional survey. Using multistage random sampling, we enrolled 64 participants across Malang city, divided into frail and robust groups. We analyzed the plasma IL-6 levels and CD4/CD8 ratio using an independent t-test and the Mann–Whitney U test. Results: Significant differences between frail and robust elders were found in age and education level, with the frail participants being older than the robust (p=0.001) and lower educational level (p<0.001). However, plasma IL-6 levels (p=0.936) and the CD4/CD8 ratio (p=0.468) were not statistically different between the groups. Conclusion: Plasma level of IL-6 was found to increase similarly in both groups, while CD4/CD8 ratio was normal and not statistically different between the robust and frail group in elders.

Association between osteosarcopenia and cognitive frailty in older outpatients visiting a frailty clinic

PURPOSE

Osteosarcopenia and cognitive frailty are both risk factors for falls and fractures. The purpose of this study was to determine the association between osteosarcopenia and cognitive frailty.

MATERIALS AND METHODS

This was a cross-sectional secondary data analysis of the Frailty Registry Study with outpatients aged ≥65 years who visited a frailty clinic at a geriatric hospital. Osteoporosis was defined as a bone mineral density < 70% of the young adult mean. Sarcopenia was diagnosed according to the Asian Working Group for Sarcopenia 2019 criteria. Cognitive frailty was defined as the coexistence of physical frailty and mild cognitive impairment. Physical frailty was evaluated according to Japanese Cardiovascular Health Study criteria, whereas mild cognitive impairment was defined as a Mini-Mental State Examination score ≥ 24 points and a score ≤ 25 points on the Japanese version of the Montreal Cognitive Assessment. We performed multivariable logistic regression analysis to investigate the association between osteosarcopenia and cognitive frailty.

RESULTS

The data of 432 patients were analysed. The prevalence of osteosarcopenia and cognitive frailty was 10.2% and 20.8%, respectively. Logistic regression analysis revealed that osteosarcopenia was independently associated with cognitive frailty with a higher odds ratio than osteoporosis or sarcopenia alone. Lost points in visuospatial abilities/executive functions and orientation were significantly associated with osteosarcopenia.

CONCLUSIONS

Combination of osteoporosis and sarcopenia is more likely to be associated with physical and cognitive decline than osteoporosis and sarcopenia alone. The mechanism by which osteosarcopenia is associated with decreased visuospatial abilities/executive functions and orientation needs to be addressed.

Prioritizing movement to address the frailty phenotype in heart failure

Frailty is a highly prevalent multisystem syndrome in older adults with heart failure (HF) and is associated with poor clinical prognosis and increased complexity of care. While frailty is neither disease nor age specific, it is a clinical manifestation of aging-related processes that reflects a reduced physiological ability to tolerate and recover from stress associated with aging, disease, or therapy. Within this context, physical frailty, which is distinctly oriented to physical functional domains (e.g., muscle weakness, slowness, and low activity), has been recognized as a critical vital sign in older persons with HF. Identification and routine assessment of physical frailty, using objective physical performance measures, may guide the course of patient-centered treatment plans that maximize the likelihood of improving clinical outcomes in older HF patients. Exercise-based rehabilitation is a primary therapy to improve cardiovascular health in patients with HF; however, the limited evidence supporting the effectiveness of exercise tailored to older and frail HF patients underscores the current gaps in management of their care. Interdisciplinary exercise interventions designed with consideration of physical frailty as a therapeutic target may be an important strategy to counteract functional deficits characteristic of frailty and HF, and to improve patient-centered outcomes in this population. The purpose of this current review is to provide a better understanding of physical frailty and its relation to management of care in older patients with HF. Implications of movement-based interventions, including exercise and physical rehabilitation, to prevent or reverse physical frailty and improve clinical outcomes will further be discussed.

Sarcopenia and Frailty in Chronic Liver Damage: Common and Different Points

AIM

To elucidate the common and different points between sarcopenia and frailty in chronic liver damage (CLD).

PATIENTS AND METHODS

Patients with both grip strength decline and skeletal muscle index decline were regarded as sarcopenia. Frailty was defined as a syndrome in which 3 or more of the following criteria were met: i) exhaustion, ii) body weight loss, iii) slow walking speed, iv) muscle weakness, and v) low physical activity.

RESULTS

Sarcopenia and frailty were identified in 52 patients (15.2%) and 46 (13.5%), respectively. The prevalence of sarcopenia and frailty was well stratified according to age and the liver cirrhosis (LC) status. In the multivariate analysis, we identified significant factors for sarcopenia: i) age, ii) LC, iii) body mass index and iv) extracellular water (ECW) to total body water (TBW) ratio, while only the ECW to TBW ratio was significant for frailty.

CONCLUSION

Sarcopenia and frailty in CLD should be separately evaluated.

Factors associated with falls in community-dwelling older adults: an analysis based on subscales of the frailty screening index

[Purpose] We aimed to obtain new findings by investigating the relationship between the presence or absence of falls and the results from the Frailty Screening Index (FSI), which can be easily carried out. [Participants and Methods] A total of 780 community-dwelling older adults (age ≥65 years) were classified based on whether they had fallen in the past year as those who had fallen at least once (fall group), and those who had not (non-fall group). We compared the study groups using sub-items of the FSI to extract more specific fall-related factors. The FSI is a questionnaire that comprises five items with simple ‘yes/no’ responses. [Results] The following three out of five sub-items of the FSI were extracted as fall-related factors: 1) “no” to the question, “Do you do physical exercise, like walking, at least once a week?”; 2) “yes” to the question, “Do you think you walk slower than before?”; and 3) “yes” to the question, “Have you felt tired for no reason (in the past two weeks)?” [Conclusion] The study results suggest the significance of paying attention to participant responses to the sub-items on the FSI, instead of merely determining their frailty risk based on their total score.

Characteristics of patients discontinuing outpatient services under long-term care insurance and its effect on frailty during COVID-19

BACKGROUND

Among community-dwelling older adults who require long-term care and use outpatient rehabilitation services, we aimed to examine the characteristics of patients who discontinued using outpatient rehabilitation services to prevent exposure to COVID-19 and the effects of this discontinuation on patient frailty.

METHODS

Participants were 119 older adults (69 males, 50 females; average age 77.3 ± 8.3 years) requiring long-term care who used outpatient rehabilitation services. Our outpatient rehabilitation service involved day care for older adults undergoing rehabilitation including pick-up and drop-off services under the long-term care insurance system. They were divided into two groups: participants who discontinued using outpatient rehabilitation services and participants who continued their use. To find the factors associated with this discontinuation, binomial logistic regression analysis was performed, in which the following independent variables were used: gender, age, height, weight, long-term care level, grip strength, and normal walking speed. Frailty status was investigated in April 2020 and again in September 2020 through interviews and telephone surveys utilizing the Frailty Screening Index.

RESULTS

Women and normal walking speed were independent factors associated with the discontinuation of outpatient rehabilitation due to COVID-19. According to the results of the Frailty Screening Index, similar tendencies were exhibited in both April and September. The discontinued group indicated that they were getting less exercise and having stronger feelings of fatigue than the continuing group.

CONCLUSIONS

The findings are in accordance with other studies indicating that women are more likely to employ prevention measures against COVID-19, as seen among the community-dwelling older adults requiring long-term care who used outpatient rehabilitation services. People with higher levels of physical function were also likely to refrain from using outpatient rehabilitation services. Results further suggested that the discontinued group had more frailty-related factors (i.e., low physical activity and strong exhaustion) than the continuing group.

Timely short-term specialised palliative care service intervention for frail older people and their family carers in primary care: study protocol for a pilot randomised controlled trial

INTRODUCTION

There is limited evidence regarding the effectiveness of timely integration of short-term specialised palliative care services for older people in primary care. Using a Theory of Change approach, we developed such an intervention, the Frailty+ intervention. We present the protocol of a pilot randomised controlled trial (RCT) with a process evaluation that aims to assess the feasibility and preliminary effectiveness of the Frailty+ intervention.

METHODS AND ANALYSIS

We will conduct a pilot RCT in Flanders, Belgium. Frail older people who are discharged to home from hospital will be identified and recruited. Seventy-six will be randomly assigned either to the control group (standard care) or the intervention group (Frailty+ intervention alongside standard care). Data will be collected from patients and family carers. At the core of the Frailty+ intervention is the provision of timely short-term specialised palliative care facilitated by a nurse from the specialised palliative home care service over a period of 8 weeks. We will assess feasibility in terms of recruitment, randomisation, acceptability of the intervention, retention in the programme and data completion. The primary outcome for assessing preliminary effectiveness is a mean score across five key symptoms that are amenable to change (ie, breathlessness, pain, anxiety, constipation, fatigue), measured at baseline and 8 weeks post-baseline. The process evaluation will be conducted in the intervention group only, with measurements at 8-11 weeks post-baseline to evaluate implementation, mechanisms of change and contextual factors.

ETHICS AND DISSEMINATION

The study has been approved by the ethics committee of University Hospital Ghent. Results will be used to inform the design of a full-scale RCT and will be published in a peer-reviewed, open access journal.

TRIAL REGISTRATION NUMBER

ISRCTN39282347; Pre-results.

A Narrative Review on Sarcopenia in Type 2 Diabetes Mellitus: Prevalence and Associated Factors

Type 2 diabetes mellitus (T2DM) represents a major health burden for the elderly population, affecting approximately 25% of people over the age of 65 years. This percentage is expected to increase dramatically in the next decades in relation to the increased longevity of the population observed in recent years. Beyond microvascular and macrovascular complications, sarcopenia has been described as a new diabetes complication in the elderly population. Increasing attention has been paid by researchers and clinicians to this age-related condition—characterized by loss of skeletal muscle mass together with the loss of muscle power and function—in individuals with T2DM; this is due to the heavy impact that sarcopenia may have on physical and psychosocial health of diabetic patients, thus affecting their quality of life. The aim of this narrative review is to provide an update on: (1) the risk of sarcopenia in individuals with T2DM, and (2) its association with relevant features of patients with T2DM such as age, gender, body mass index, disease duration, glycemic control, presence of microvascular or macrovascular complications, nutritional status, and glucose-lowering drugs. From a clinical point of view, it is necessary to improve the ability of physicians and dietitians to recognize early sarcopenia and its risk factors in patients with T2DM in order to make appropriate therapeutic approaches able to prevent and treat this condition.

Frailty Status Typologies in Spanish Older Population: Associations with Successful Aging

Background: Defining frailty typologies would contribute to guiding specific care interventions. These typologies could additionally be related to different health outcomes. This study aims at identifying subgroups of frail older adults based on the physical frailty phenotype and examining the relationships of these frailty profiles with quality of life and perceived health. Methods: This study relies on data from the SHARE project, namely a representative sample of 1765 Spanish-dwelling older adults identified as frail or pre-frail. Analysis included general descriptive statistics, exploratory latent class analysis (LCA) to determine the number of frailty subgroups, and LCA with covariates to examine differential relationships with markers of successful aging. Results: Statistical criteria and interpretability of the classes suggested that the LCA model with four classes should be retained. Class 1 was identified as the “frail people” group, Class 2 “activity problems” group, Class 3 “fatigued” group, and those belonging to Class 4 “lack of strength” group. Final LCA with covariates showed lower levels of quality of life and perceived health of the “frail” as compared to other frailty subgroups. Conclusion: This study revealed four different patterns of frailty attributes and further offered evidence on individuals’ differential status of health regarding distinct frailty conditions.

Hypertension, heart failure, and frailty in older people: A common but unclear situation

Hypertension and heart failure are common conditions in older people. Comorbidity, together with aging, is commonly associated with frailty, which is a cause of a worse prognosis, more hospitalizations, increased dependency, and mortality. Despite being increasingly common conditions, data on the prevalence and influence of frailty in hypertensive older patients with HF are lacking. This may be due to the multidimensional aspects of frailty and the differing tools used to evaluate it. Nevertheless, in clinical practice, it is common to see frail hypertensive patients with HF but the specific characteristics of this group of patients, including multimorbidity and frailty, and the lack of data from registries or randomized clinical trials make the diagnosis and management of these patients more difficult than in those of other ages. This review focuses on what is known and on where future investigations should focus in this common but unclear situation.

Frailty and Sleep Disorder in Chronic Liver Diseases

We aimed to investigate the association in frailty and sleep disorder as assessed by the Japanese version of Pittsburgh Sleep Quality Index (PSQI-J) in patients with chronic liver diseases (CLDs, n = 317, 141 males). Frailty was determined using the following five phenotypes: unintentional body weight loss, self-reported exhaustion, muscle weakness, slow walking speed, and low physical activity. Sleep disorder was defined as patients with PSQI-J score 6 or greater. Robust (phenotype, 0), prefrail (1 or 2 phenotypes) and frailty (3 phenotypes or greater) were observed in 101 (31.9%), 174 (54.9%) and 42 (13.2%), respectively. The median (interquartile range (IQR)) PSQI-J score was 4 (3, 7). Sleep disorder was found in 115 patients (36.3%). The median (IQR) PSQI-J scores in patients of the robust, prefrail, and frail groups were 3 (2, 5), 5 (3, 7), and 8 (4.75, 10.25), respectively (p < 0.0001 between any two groups and overall p < 0.0001). The ratios of sleep disorder in patients with robust, prefrail and frailty were 15.8% (16/101), 39.1% (68/174), and 73.8% (31/42), respectively (overall p < 0.0001). In conclusion, CLD patients with frailty can involve poorer sleep quality. As sleep disorder in CLDs is potentially remediable, future frailty-preventive strategies must take sleep complaints into account.

Close Correlation between Frailty and Depressive State in Chronic Liver Diseases

Background and objectives: Few data with regard to the relevance between depression and frailty in chronic liver disease (CLD) patients are currently available. We aimed to elucidate the relationship between frailty and depression as evaluated by the Beck Depression Inventory—2nd edition (BDI-II) in CLD patients (n = 340, median age = 65.0 years). Methods: Frailty was defined as a clinical syndrome in which three or more of the following criteria were met: body weight loss, exhaustion, muscle weakness, slow walking speed and low physical activity. Depressive state was defined as BDI-II score 11 or greater. Results: Robust (frailty score = zero), prefrail (frailty score = one or two) and frailty were identified in 114 (33.5%), 182 (53.5%) and 44 (12.9%). The median BDI-II score was five. Depressive state was identified in 84 patients (24.7%). The median BDI-II scores in patients with robust, prefrail and frail traits were 2, 7 and 12.5 (robust vs. prefrail, p < 0.0001; prefrail vs. robust, p = 0.0003; robust vs. frail, p < 0.0001; overall p < 0.0001). The proportions of depressive state in patients with robust, prefrail and frail traits were 3.51%, 30.77% and 54.55% (robust vs. prefrail, p < 0.0001; prefrail vs. robust, p = 0.0046; robust vs. frail, p < 0.0001; overall p < 0.0001). BDI-II score significantly correlated with frailty score (r_s = 0.5855, p < 0.0001). Conclusions: The close correlation between frailty and depression can be found in CLD. Preventing frailty in CLD should be approached both physiologically and psychologically.

Anthropometric Measurements and Frailty in Patients with Liver Diseases

There have been scarce data regarding the relationship between frailty and anthropometry measurements (AMs) in patients with chronic liver diseases (CLDs). We aimed to elucidate the influence of AMs on frailty in CLDs (median age = 66 years, 183 men and 192 women). AMs included arm circumference, triceps skinfold thickness, calf circumference (CC), waist circumference, and body mass index. Frailty assessment was done by using five phenotypes (body weight loss, exhaustion, decreased muscle strength, slow walking speed, and low physical activity). Robust (frailty point 0), prefrail (frailty point 1 or 2), and frailty (frailty point 3 or more) were observed in 63 (34.4%), 98 (53.6%), and 22 (12.0%) of males, respectively, and 63 (32.8%), 101 (52.6%), and 28 (14.6%) of females, respectively. In receiver operating characteristics (ROC) curve analyses for the presence of frailty, CC had the highest area under the ROC (AUC) both in male (AUC = 0.693, cutoff point = 33.7 cm) and female (AUC = 0.734, cutoff point = 33.4 cm) participants. In the multivariate analysis associated with frailty, for the male participants, only the presence of liver cirrhosis (p = 0.0433) was identified to be significant, while among the female participants, serum albumin (p = 0.0444) and CC (p = 0.0010) were identified to be significant. In conclusion, CC can be helpful for predicting frailty, especially in female CLD patients.

Health-Related Quality of Life and Frailty in Chronic Liver Diseases

We sought to examine the relationship between frailty and health-related quality of life as evaluated using the 36-item Short-Form Health Survey (SF-36) questionnaire in Japanese chronic liver disease (CLD) patients (n = 341, 122 liver cirrhosis cases, median age = 66 years). Frailty was defined as a clinical syndrome in which three or more of the following criteria were met (frailty score 3, 4, or 5): unintentional body weight loss, self-reported exhaustion, muscle weakness (grip strength: <26 kg in men and <18 kg in women), slow walking speed (<1.0 m/s), and low physical activity. Robust (frailty score 0), prefrail (frailty score 1 or 2), and frailty were found in 108 (31.7%), 187 (54.8%), and 46 (13.5%) patients, respectively. In all eight scales of the SF-36 (physical functioning, role physical, bodily pain, general health perception, vitality, social functioning, role emotion, and mental health), and the physical component summary score and mental component summary score, each score was well stratified according to the frailty status (all p < 0.0001). In the multivariate analysis, age (p = 0.0126), physical functioning (p = 0.0005), and vitality (p = 0.0246) were independent predictors linked to the presence of frailty. In conclusion, Japanese CLD patients with frailty displayed poorer conditions, both physically and mentally.

Serum Zinc Level Is Associated with Frailty in Chronic Liver Diseases

We sought to examine the serum zinc (Zn) level and frailty in patients with chronic liver diseases (CLDs, n = 285, 107 liver cirrhosis cases, median age = 66 years). Frailty was defined as a clinical syndrome in which three or more of the following criteria were met (frailty score 3, 4, or 5): unintentional body weight loss, self-reported exhaustion, muscle weakness (grip strength: <26 kg in men and <18 kg in women), slow walking speed (<1.0 m/s), and low physical activity. Robust (frailty score 0), prefrail (frailty score 1 or 2), and frailty were found in 90 (31.6%), 157 (55.1%), and 38 (13.3%), respectively. The median serum Zn levels in patients with frailty, prefrailty, and robust were 59.7 μg/dL, 72.8 μg/dL, and 76.9 μg/dL, respectively (p-values: frailty vs. prefrail, p < 0.0001; prefrail vs. robust, p = 0.0063; frailty vs. robust, p < 0.0001; overall p < 0.0001). For all cases, variables with absolute values of correlation coefficient with frailty score (0–5) ≥ 0.3 were age (r_s = 0.3570, p < 0.0001), serum albumin (r_s = −0.3212, p < 0.0001), extracellular water to total body water ratio using bioimpedance analysis (r_s = 0.4386, p < 0.0001), and serum Zn level (r_s = −0.3406, p < 0.0001). In conclusion, decreased serum Zn level in patients with CLDs can be closely associated with the presence of frailty.

[Fall-related efficacy is associated with the progression of frailty in community-dwelling older people]

AIM

The goal of this study was to verify the association between frailty and fall-related efficacy in community-dwelling older people by performing a cross-sectional and longitudinal data analysis.

METHODS

In this study, 339 people aged 65 years and older participated in a baseline survey. Furthermore, people who were not identified as frail in the baseline survey participated in a follow-up survey 6 months later. Frailty was assessed in the baseline and follow-up surveys after 6 months using the Kihon checklist. Fall-related efficacy was assessed at baseline using the short Falls Efficacy Scale International (short FES-I). Potential confounding factors, such as the lower limb functions and psychological functions, were also investigated at baseline. The association between frailty and short FES-I was analyzed using a logistic regression analysis adjusted for potential confounding factors.

RESULTS

At baseline and the follow-up survey, 10.1% and 6.3% of the participants were judged to demonstrate frailty, respectively. The results of the baseline and follow-up data analysis showed that even if potential confounding factors were adjusted for, the short FES-I was significantly associated with frailty. Furthermore, the ability to distinguish the onset of frailty using the short FES-I was analyzed using a receiver operating characteristic curve, and the area under curve, sensitivity, and specificity values were 0.78, 0.92 and 0.56, respectively.

CONCLUSIONS

A clear association between frailty and fall-related efficacy was thus observed, as indicated in the cross-sectional and longitudinal data analysis. Furthermore, based on the results of the longitudinal data analysis, the short FES-I was found to be able to predict the progression of frailty and it can thus be a useful screening tool for assessing frailty.