The Frailty Identity Crisis

Understanding Frailty: Perspectives and Experiences of Rural Older Adults in India

OBJECTIVES

In India, frailty has been predominantly studied as a physiological aspect, overlooking the subjective perceptions of community-dwelling older adults, which holds global significance. This study aims to explore frailty perceptions among community-dwelling older adults, comparing those enrolled in a geriatric welfare program facility to those not-enrolled.

METHODS

A cross-sectional design with a qualitative descriptive framework was employed, using focus group methodology. The study took place in rural West Bengal, located in eastern India, with a sample of 27 participants aged 60-87 years. Data collection occurred between October 2018 and January 2020, conducted through a face-to-face, semistructured discussion guide. Thematic analysis was performed to ensure data saturation and reliability.

RESULTS

Three key themes emerged from the analysis: (a) Perceptions of frailty were associated with aging, functional dependence, and psychosocial health, (b) Exposure to a scientific definition led to an ideological dilemma influenced by personal experiences, (c) Walking speed and grip strength were prominent components of frailty. The findings revealed that there was no difference in perception between program-enrolled and nonenrolled older adults, likely due to the concept of frailty being new to all participants. However, it was noteworthy that participants enrolled in the welfare program exhibited a resilient mindset toward the definition and demonstrated a proactive interest in preserving their overall health.

DISCUSSION

This novel study underscores the necessity of enhancing community awareness and integrating frailty management into the Indian health care system, which is yet to be fully integrated, aiming to promote the well-being of older adults.

Influence of frailty status on the health-related quality of life in older patients with chronic low back pain: a retrospective observational study

PURPOSE

Understanding the influence of frailty on health-related quality of life (HRQoL) in older individuals experiencing chronic low back pain can provide valuable insights into the impact of frailty. Therefore, the aim of our study is to assess how different frailty statuses among older outpatients with chronic low back pain affect their HRQoL.

METHODS

Patients aged 60 and above with chronic low back pain were recruited from March 2022 to February 2023. Frailty was assessed via the frailty phenotype questionnaire, and HRQoL was evaluated using the EQ-5D-5L. Multiple regression models were used to explore the influence of frailty status on the EQ-5D-5L index and EQ-VAS. Logistic regression was used to determine odds ratios for the impact of frailty status on belonging to the lowest EQ-5D-5L index quartile.

RESULTS

A total of 1,054 participants were classified into robust (29.8%), pre-frail (47.7%), and frail (22.5%) groups. Frailty was significantly associated with declining HRQoL. Pre-frail and frail statuses were inversely linked to the EQ-5D-5L index, with significantly higher odds of scoring in the lowest quartile compared to robust individuals. Stratification analysis identified sex as an effect modifier, emphasizing a more substantial association between frailty and the lowest EQ-5D-5L index quartile in female patients.

CONCLUSIONS

A significant association exists between frailty and reduced HRQoL in patients with chronic low back pain. This association was predominant in female patients. Furthermore, considering the dynamic nature of frailty, early detection and effective interventions targeting pre-frailty are essential to delaying the transition to full frailty and improving HRQoL.

Overlap between Osteosarcopenia and Frailty and their Association with Poor Health Conditions: The Bushehr Elderly Health Program

BACKGROUND

The aim of this study was to investigate the association of osteosarcopenia with frailty and poor health conditions among older Iranian adults.

METHODS

This cross-sectional study analyzed data from the Bushehr Elderly Health Program. Osteosarcopenia was defined as the presence of osteopenia/osteoporosis and sarcopenia, while the Fried criteria were used to assess frailty. We assessed the history of falls and health-related quality of life (HRQoL), including physical and mental component summaries (PCS and MCS, respectively), history of fractures, activities of daily living (ADL), and instrumental activities of daily living (IADL), as indicators of poor health conditions.

RESULTS

This study included a total of 2,371 older adults. The prevalence rates of osteosarcopenia-only, frailty-only, and osteosarcopenia with frailty were 17.4%, 3%, and 4.8%, respectively. The prevalence of a history of falls, poor ADL, and poor IADL was significantly higher in the frailty-only and osteosarcopenia with frailty groups. Osteosarcopenia with frailty was significantly associated with a history of falls (adjusted odds ratio [adjOR]=1.94; 95% confidence interval [CI], 1.20-3.15), poor ADL (adjOR=2.85; 95% CI, 1.81-4.50), and poor IADL (adjOR=5.09; 95% CI, 2.85-9.11). However, the frailty-only group also showed an association with falls and poor ADL and IADL. Only osteosarcopenia was associated with an increased OR for fracture. Frailty had the greatest effect on the MCS and PCS scores, whereas osteosarcopenia with frailty had a moderate impact.

CONCLUSION

Osteosarcopenia with frailty significantly increased the odds of falls, poor ADL, poor IADL, and lower HRQoL compared with the robust group. Combined osteosarcopenia and frailty were not associated with poor health. These findings indicate the importance of diagnosing osteosarcopenia and frailty as separate entities to provide appropriate interventions and treatment.

The lived experience of frailty: beyond classification and towards a holistic understanding of health

PURPOSE

Frailty is characterised by decreased physiological reserves and vulnerability to stressors. Although scales, such as the Fried's Frailty Phenotype (FP), Frailty Index (FI), and Clinical Frailty Scale (CFS), are used to identify frailty, the lived experience of frailty remains understudied.

METHODS

This cross-sectional observational research involved participants aged 65 years and older from Wave 1 of The Irish Longitudinal Study on Ageing (TILDA). Participants were categorised into four independent groups: three frail groups based on the aforementioned scales and a non-frail group. Quantitative variables, including self-rated health, CASP-19 quality-of-life score, and frequency of social activities, were analysed and described.

RESULTS

The study encompassed 1999 participants with an average age of 72 years, of whom 51% were women. FP exclusively identified 1.6% as frail (n = 32), FI 11.7% (n = 233), and CFS 6.8% (n = 135). More than 60% of all those classified as frail reported their health as good, very good, or excellent, with the lowest proportion (64%) being among frail by FI participants. Frail by FI participants exhibited the lowest mean average CASP-19 score, yet it remained relatively high at 39 out of 57 points. Over 77% of all frail individuals engaged in active leisure activities at least once a month.

CONCLUSION

This study underscores the need to comprehend frailty holistically beyond its mere identification. It challenges the prevailing belief that frailty inevitably leads to impaired quality of life and limited social engagement. The findings advocate for a reassessment of how both the general public and healthcare professionals perceive frailty.

Effectiveness of subjective support-focused cognitive behavioral therapy on depressive symptoms among (pre)frail community-dwelling older adults: A randomized controlled trial

BACKGROUND

Subjective support could ameliorate the adverse effect of (pre)frailty on depressive symptoms. However, there is scarce evidence regarding subjective support-focused intervention in preventing depression among (pre)frail community-dwelling older adults. This study aims to explore the effectiveness of subjective support-focused cognitive behavioral therapy (SS-CBT) in preventing depression among this group of population.

METHODS

A total of 100 community-dwelling (pre)frail older adults were recruited from six communities in a Chinese city and were randomized to an 8-week SS-CBT group or a wait-list control group. Depressive symptoms and subjective support were assessed at baseline (T0), and at 8 week (T1), 12 week (T2), 16 week (T3) after randomization. Generalized estimating equation was used to examine the effectiveness of SS-CBT on depressive symptoms and subjective support. Hierarchical linear regression models and Bootstrapping method were used to examine whether subjective support mediated the effectiveness of SS-CBT on depressive symptoms.

RESULTS

Participants in SS-CBT group reported significant reduction in depressive symptoms (Wald χ2 = 20.800, p < 0.001) and improvement in subjective support (Wald χ2 = 92.855, p < 0.001) compared to those in wait-list control group. Changes in subjective support mediated the effectiveness of SS-CBT on changes in depressive symptoms.

LIMITATIONS

Restricted regions to recruit participants, inclusion of the most motivated participants, lack of diagnosis of depression, potential experimenter bias and contamination, short follow-up period, and lack of an active control group.

CONCLUSIONS

The findings support the benefits of SS-CBT in preventing depression among (pre)frail community-dwelling older adults, and provide insight into possible mechanisms.

Cognitive frailty and its association with depression, anxiety and stress during the COVID-19 pandemic among older adults in the transforming cognitive frailty into later-life self-sufficiency (AGELESS) study

BACKGROUND

Cognitive frailty describes the co-occurrence of cognitive impairment and physical frailty and is classified into reversible and irreversible phenotypes. Data on the impact of COVID-19 pandemic imposed lockdowns, locally known as the Movement Control Order (MCO), on the psychological status of cognitively frail older adults remain scarce. Therefore, this study aimed to determine the relationship between depression, anxiety, stress and cognitive frailty among older adults during the MCO.

METHOD

Participants aged above 60 years from three ageing cohorts in Malaysia were interviewed virtually. The Fatigue, Resistance, Ambulation, Illness and Loss of Weight scale, blind Montreal Cognitive Assessment, 15-item Geriatric Depression Scale, anxiety subscale of Depression, Anxiety and Stress Scale and four-item Perceived Stress Scale measured frailty, mild cognitive impairment (MCI), depression, anxiety and stress, respectively.

RESULTS

Cognitive frailty data were available for 870 participants, age (mean ± SD) = 73.44 ± 6.32 years and 55.6% were women. Fifty-seven (6.6%) were robust, 24 (2.8%) had MCI, 451 (51.8%) were pre-frail, 164 (18.9%) were pre-frail+MCI, 119 (13.7%) were frail and 55 (6.3%) were frail+MCI. There were significant differences in depression and anxiety scores between the controlled MCO and recovery MCO. Using multinomial logistic regression, pre-frail (mean difference (95% confidence interval, CI) = 1.16 (0.932, 1.337), frail (1.49 (1.235, 1.803) and frail+MCI (1.49 (1.225, 1.822)) groups had significantly higher depression scores, frail (1.19 (1.030, 1.373)) and frail+MCI (1.24 (1.065, 1.439)) had significantly higher anxiety scores and pre-frail (1.50 (1.285, 1.761)), frail (1.74 (1.469, 2.062)) and frail+MCI (1.81 (1.508, 2.165)) had significantly higher stress scores upon adjustments for the potential confounders. The MCO was a potential confounder in the relationship between depression and prefrail+MCI (1.08 (0.898, 1.340)).

CONCLUSION

Frail individuals with or without MCI had significantly higher depression, anxiety and stress than those who were robust. Increased depression and stress were also observed in the pre-frail group. Interventions to address psychological issues in older adults during the COVID-19 pandemic could target prefrail and frail individuals and need further evaluation.

Older women's view on frailty and an Emergency Department evidence-based Frailty Intervention Team (FIT) program: An evaluation using the Reach, Effectiveness, Adoption, Implementation, Maintenance RE-AIM framework

BACKGROUND

Older women have higher levels of frailty resulting in disability and reduced quality of life. Presentation to an Emergency Department (ED) is an opportunity to address frailty and provide tailored interventions to promote function. An ED allied health team integrated frailty assessment and interventions into care through a 'Frailty Intervention Team' (FIT) program.

METHODS

A prospective study informed by the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to evaluate the FIT program tailored to female older adults. The purpose of this project was to evaluate the FIT program over a three-month period and use the findings to further develop the intervention.

RESULTS

Over three-months, 192 older females (>70 years) were identified with mild frailty and discharged directly home. Ninety percent were offered the FIT program with 83.3 % accepting all recommended frailty management strategies. Ninety percent of patients were satisfied with the FIT program, however staff and patient barriers to provision of frailty services were identified.

CONCLUSIONS

The FIT program was largely adopted by staff and accepted by older female patients with mild frailty in the ED. However, program effectiveness was limited by gaps in communication about frailty in the ED and implementation of frailty management strategies after discharge.

Clinical frailty is independently associated with joint-specific function and health-related quality of life in patients awaiting a total hip or knee arthroplasty

The aims were to assess whether preoperative joint-specific function (JSF) and health-related quality of life (HRQoL) were associated with level of clinical frailty in patients waiting for a primary total hip arthroplasty (THA) or knee arthroplasty (KA). Patients waiting for a THA (n = 100) or KA (n = 100) for more than six months were prospectively recruited from the study centre. Overall,162 patients responded to the questionnaire (81 THA; 81 KA). Patient demographics, Oxford score, EuroQol five-dimension (EQ-5D) score, EuroQol visual analogue score (EQ-VAS), Rockwood Clinical Frailty Score (CFS), and time spent on the waiting list were collected. There was a significant correlation between CFS and the Oxford score (THA r = -0.838; p < 0.001, KA r = -0.867; p < 0.001), EQ-5D index (THA r = -0.663, p =< 0.001; KA r = -0.681; p =< 0.001), and EQ-VAS (THA r = -0.414; p < 0.001, KA r = -0.386; p < 0.001). Confounding variables (demographics and waiting time) where adjusted for using multiple regression analysis. For each 8.5 (THA, 95% CI 7.1 to 10.0; p < 0.001) and 9.9 (KA, 95% CI 8.4 to 11.4; p < 0.001) point change in the Oxford score, there was an associated change in level of the CFS. For each 0.16 (THA, 95% CI 0.10 to 0.22; p < 0.001) and 0.20 (KA, 95% CI 0.12 to 0.27; p < 0.001) utility change in EQ-5D, there was an associated change in level of the CFS. EQ-VAS (THA, B = -11.5; p < 0.001, KA B = -7.9; p = 0.005) was also associated with CFS. JSF and HRQoL in patients awaiting THA or KA for more than six months, were independently associated with level of clinical frailty. With further prospective studies, clinical frailty may prove to be a useful metric to assist in the prioritization of arthroplasty waiting lists.

A qualitative study exploring the lived experiences of patients living with mild, moderate and severe frailty, following hip fracture surgery and hospitalisation

It is well recognised that hip fracture surgery is associated with a negative impact on short and long-term post-operative physical health and emotional well-being for patients. Furthermore, these patients are known to be frail with multiple co-morbidities. This study explores how frailty shapes the lived experiences of rehabilitation and recovery for patients who have undergone hip fracture surgery. Semi-structured interviews were conducted with sixteen participants, recently discharged from hospital following hip fracture surgery. Interpretative phenomenological analysis was applied to explore the lived experiences of frail patients and ascertain important themes. Patient experiences were captured in seven overarching themes: 1) the hospital as a place of "safety", 2) placing trust in others, 3) the slow recovery journey impeded by attitude and support, 4) maintaining autonomy and dignity whilst feeling vulnerable, 5) seeking a new normal, 6) loneliness and social isolation and 7) the ageing body. Based on our study findings, we have been able to suggest a number of opportunities to improve support for frailer patients in finding a new routine to their everyday lives, these include on-going physical and psychological support, information and education and a robust pathway for transition of care into the community. A conceptual thematic diagram is presented which helps to understand the experience and the complex needs of frail older people undergoing hip fracture surgery.

General self-efficacy and frailty in hospitalized older patients: The mediating effect of loneliness

This study aimed to explore the relationship between general self-efficacy and frailty in hospitalized older adults with chronic diseases, and to examine the mediating role of loneliness. A total of 327 hospitalized older patients aged 60 years or above with chronic diseases were recruited. Cross-sectional data on the patients' general self-efficacy, frailty and loneliness were collected using questionnaires. The PROCESS macro of the bias correction bootstrapping method was used to test the mediation model. The results showed that the significant mediating role of loneliness between general self-efficacy and frailty (B = -0.735, 95% CI [-0.923, -0.564]) explained 42.4% of the total effect of general self-efficacy on frailty. These findings highlighted the importance of loneliness in older patients with chronic diseases in hospital, especially those with low general self-efficacy.

Exploring ageism as a structure of consciousness across the female lifecourse through the work of Simone de Beauvoir

Drawing on the work of Simone de Beauvoir, this paper considers ageism as a structure of consciousness, with important convergences with, as well as departures from, those associated with gender. Specifically, it explores the double consciousness through which the self is experienced negatively as old, at two points in a woman’s lifecourse, namely mid-life and ‘old age’. The first kind of ageism works through the double standard of ageing and the gender hierarchy, whereby women can no longer successfully comply with the objectification of the male gaze. This is a moment of intense age consciousness, tainted by a gendered narrative of decline, working jointly from the outside in and from the inside out. The second form of ageism has its source in the social world, in the reactions of other people to old age, resulting in an uneasy dialectic between one’s own sense of an ageless or youthful self and the alien view of self as old. The paper proceeds as follows. After a brief account of Beauvoir’s general philosophical approach, I compare and contrast the doubled consciousness associated with ageing as a woman and with ageing in a more general sense as described in The Second Sex and The Coming of Age respectively. I then flesh out this conceptual framework by drawing on fiction and auto-fiction written by Beauvoir herself. Together, this approach vividly illuminates the important interconnections and intersections between ageism and sexism, the way they work together, as well as separately, across the female lifecourse.

The Frail Depressed Patient: A Narrative Review on Treatment Challenges

Although the public importance of frailty is widely acknowledged by the World Health Organization, physical frailty is still largely neglected in geriatric mental health care. Firstly in this narrative review, we summarize the knowledge on the epidemiology of the association between depression and frailty, whereafter implications for treatment will be discussed. Even though frailty and depression have overlapping diagnostic criteria, epidemiological studies provide evidence for distinct constructs which are bidirectionally associated. Among depressed patients, frailty has predictive validity being associated with increased mortality rates and an exponentially higher fall risk due to antidepressants. Nonetheless, guidelines on the treatment of depression neither consider frailty for risk stratification nor for treatment selection. We argue that frailty assessment enables clinicians to better target the pharmacological and psychological treatment of depression as well as the need for interventions targeting primarily frailty, for instance, lifestyle interventions and reduction of polypharmacy. Applying a frailty informed framework of depression treatment studies included in a meta-analysis reveals that the benefit–harm ratio of antidepressants given to frail depressed patients can be questioned. Nonetheless, frail-depressed patients should not withhold antidepressants as formal studies are not available yet, but potential adverse effects should be closely monitored. Dopaminergic antidepressants might be preferable when slowness is a prominent clinical feature. Psychotherapy is an important alternative for pharmacological treatment, especially psychotherapeutic approaches within the movement of positive psychology, but this approach needs further study. Finally, geriatric rehabilitation, including physical exercise and nutritional advice, should also be considered. In this regard, targeting ageing-related abnormalities underlying frailty that may also be involved in late-life depression such as low-grade inflammation might be a promising target for future studies. The lack of treatment studies precludes firm recommendations, but more awareness for frailty in mental health care will open a plethora of alternative treatment options to be considered.

Cognitive frailty among community-dwelling rural elderly population of West Bengal in India

OBJECTIVES

There has been growing interest in the links between physical frailty and cognitive impairment: both can increase the risk of emerging life-threatening health problems and are currently prominent within the global geriatric health agenda. A recent consensus proposes the idea of 'cognitive frailty' defined by the presence of both physical frailty and cognitive impairment in the absence of dementia. Present study is intended to determine the prevalence of cognitive frailty and its associated factors.

METHODS

Cross-sectional survey was conducted among the rural community-dwelling elderly population of West Bengal, India (n = 510), without diagnosed dementia at baseline. An Interview-based questionnaire was administered to obtain information on sociodemographic, physical and psychosocial characteristics. Study participants were categorized as non-cognitive impairment (NCI) and cognitive impairment (CI) by Bangla Adaptation of Mini-Mental State Exam (BMSE ≤ 25) scale, as non-physical frailty (NPF) and physical frailty (PF) using Modified Fried Frailty Phenotype (FP ≥ 3) scale, as robust (NPF + NCI), pre-cognitive frailty (NPF + CI or PF + NCI) and cognitive frailty (PF + CI).

RESULTS

The overall prevalence of cognitive frailty was 21.8%. In multinomial regression analysis, final model indicated that increasing age, being woman, out-of-wedlock, poor education and non-working sociodemographic status had significant association with cognitive frailty. Poor nutritional status, low health-related quality of life and depression are also prone among the cognitively frail participants.

CONCLUSIONS

Present study allows us to understand complementary relationships between sociodemographic, physical, psychosocial characteristics and cognitive frailty. There is a dire need for multidimensional approach for providing appropriate and comprehensive geriatric health care for developing countries like India.

The Psychosocial Effects of Frailty on Women

Certain psychosocial elements, such as depression, anxiety, stress, lack of social support, and loneliness, should be considered as part of frailty. Women are more likely to be frail toward the end of life, because they live longer and are less likely to develop diseases with abrupt ends. Women are also more prone to develop psychosocial elements associated with frailty because of their lifetime stressors, poverty, and loneliness at the end of life. Clinicians should recognize this phenomenon and create early interventions to ensure women are able to live according to their preferences during the last part of their lives.

"Falling off the wagon": older adults' experiences of living with frailty in rural arctic communities

Most populations around the world are ageing. The proportion of older adults in the population is larger and is growing more rapidly in rural communities than in urban areas. Longevity increases the risk of frailty. Our aim was to explore how single-living frail older adults experience living with frailty in everyday life in rural Arctic areas. Over eight months, we conducted a series of three interviews with eight older adults identified as frail by home care services in two rural municipalities in northern Norway. We conducted a thematic analysis. We generated three themes. Frailty as a dynamic phenomenon indicated that the participants’ experiences of frailty varied over time. Frailty as part of old age referred to the findings that many participants tried to adapt to the changing circumstances, while others found it more challenging to accept the experienced limitations. Frailty in a rural Arctic context concerned the findings that the rural Arctic environment affected the participants’ experiences of frailty due to its long, snowy winters; long distances between communities and municipal centres; and out-migration. Our results demonstrate that frailty is a consequence of the interplay between ageing persons and their physical and social environments.

Subtypes of Late-Life Depression: A Data-Driven Approach on Cognitive Domains and Physical Frailty

BACKGROUND

With increasing age, symptoms of depression may increasingly overlap with age-related physical frailty and cognitive decline. We aim to identify late-life-related subtypes of depression based on measures of depressive symptom dimensions, cognitive performance, and physical frailty.

METHODS

A clinical cohort study of 375 depressed older patients with a DSM-IV depressive disorder (acronym NESDO). A latent profile analysis was applied on the three subscales of the Inventory of Depressive Symptomatology, as well as performance in five cognitive domains and two proxies for physical frailty. For each class, we investigated remission, dropout, and mortality at 2-year follow-up as well as change over time of depressive symptom severity, cognitive performance, and physical frailty.

RESULTS

A latent profile analysis model with five classes best described the data, yielding two subgroups suffering from pure depression ("mild" and "severe" depression, 55% of all patients) and three subgroups characterized by a specific profile of cognitive and physical frailty features, labeled as "amnestic depression," "frail-depressed, physically dominated," and "frail-depressed, cognitively dominated." The prospective analyses showed that patients in the subgroup of "mild depression" and "amnestic depression" had the highest remission rates, whereas patients in both frail-depressed subgroups had the highest mortality rates.

CONCLUSIONS

Late-life depression can be subtyped by specific combinations of age-related clinical features, which seems to have prospective relevance. Subtyping according to the cognitive profile and physical frailty may be relevant for studies examining underlying disease processes as well as to stratify treatment studies on the effectiveness of antidepressants, psychotherapy, and augmentation with geriatric rehabilitation.

Changes in psychological distress before and during the COVID-19 pandemic among older adults: the contribution of frailty transitions and multimorbidity

AIM

To investigate changes in psychological distress in community-dwelling older adults before and during the coronavirus disease 2019 (COVID-19) pandemic and the contribution of frailty transitions and multimorbidity in predicting the psychological distress.

METHODS

Prospective repeated-measures cohort study on a sample of participants aged 60 and over. A total of 2, 785 respondents at the baseline (May 2019) were followed during the COVID-19 (August 2020). The changes in psychological distress before and during the COVID-19 were assessed using generalised estimation equations with adjusting for sex, age, education, economic status, marital status, tea drinking status, smoking status, alcohol drinking status, sedentary time, sleep quality and activities of daily living.

RESULTS

The psychological distress of older people has significantly increased in August 2020 compared with May 2019. Both older adults who remained frail and transitioned into frail state reported more psychological distress during the COVID-19. Similarly, both pre-existing multimorbidity and emerging multimorbidity groups were associated with more psychological distress. The group of frailty progression who reported new emerging multimorbidity showed more increase in psychological distress in comparison with those who remained in the non-frail state who reported no multimorbidity.

CONCLUSION

Psychological distress has increased among the community-dwelling older adults during the COVID-19 pandemic, and sustained and progressive frail states as well as multimorbidity were all associated with a greater increase of psychological distress. These findings suggest that future public health measures should take into account the increased psychological distress among older people during the COVID-19 pandemic, and the assessment of frailty and multimorbidity might help in warning of psychological distress.

Relationship Between Frailty and Depression Among Community-Dwelling Older Adults: The Mediating and Moderating Role of Social Support

BACKGROUND AND OBJECTIVES

Frailty is associated with depression in older adults and reduces their social support. However, the mechanism underlying such relationship remains unclear. We aim to examine whether social support acts as a mediator or moderator in the relationship between frailty and depression.

RESEARCH DESIGN AND METHODS

This cross-sectional study was conducted among 1,779 community-dwelling older adults aged 60 and older. Frailty, social support, and depressive symptoms were measured by the Physical Frailty Phenotype, Social Support Rating Scale, and five-item Geriatric Depression Scale, respectively. Data were also collected on age, gender, years of schooling, monthly income, cognitive function, number of chronic diseases, physical function, and pain.

RESULTS

Linear regression models showed that subjective support and support utilization, but not objective support, mediated and moderated the relationship between frailty and depressive symptoms. The Johnson-Neyman technique determined a threshold of 30 for subjective support, but not for support utilization, beyond which the detrimental effect of frailty on depressive symptoms was offset.

DISCUSSION AND IMPLICATIONS

Social support underlies the association of frailty with depression, and its protective role varies by type. Interventions on depression should address improving perceptions and utilization of social support among frail older adults rather than simply providing them with objective support.

Serotonin receptor inhibitor is associated with falls independent of frailty in older adults

OBJECTIVES

To evaluate whether fall risk in older adults is associated with the use of selective serotonin receptor inhibitor (SSRI) monotherapy among geriatric outpatients, and whether this association is moderated by the presence of depressive disorder and/or frailty.

METHODS

Prospective cohort study with a 12-month follow-up and including 811 community-dwelling adults aged 60 or older from a university-based Geriatric Outpatient Unit. Major depressive disorder (MDD) was diagnosed according to DSM-5 criteria; subsyndromal depression as not meeting MDD criteria, but a Geriatric Depression Scale 15-item score ≥ 6 points. Frailty was evaluated with the FRAIL questionnaire. The association between SSRI use, depression, or both as well as the association between SSRI use, frailty, or both with falls were estimated through a generalized estimating equation (GEE) adjusted for relevant confounders.

RESULTS

At baseline, 297 patients (36.6%) used a SSRI (82 without remitted depression) and 306 (37.7%) were classified as physically frail. Frailty was more prevalent among SSRI users (44.8% versus 33.7%, p =.004). After 12 months, 179 participants had at least one fall (22.1%). SSRI use, depression as well as frailty were all independently associated with falls during follow-up. Nonetheless, patients with concurrent of SSRI usage and non-remitted depression had no higher risk compared to either remitted SSRI users or depressed patients without SSRIs. In contrast, concurrence of SSRI use and frailty increases the risk of falling substantially above those by SSRI usage or frailty alone.

CONCLUSION

SSRI usage was independently associated with falls. Especially in frail-depressed patients, treatment strategies for depression other than SSRIs should be considered.

The inter-relationship between depressed mood, functional decline and disability over a 10-year observational period within the Longitudinal Urban Cohort Ageing Study (LUCAS)

Background

The WHO defines ‘healthy ageing’ as ‘the process of developing and maintaining the functional ability’. Late-life depression and frailty compromise well-being and independence of older people. To date, there exists little research on the interaction of the dynamic processes of frailty and depression and only a few studies were longitudinal. Conclusions about the direction of effects remained uncertain.

Methods

Data were obtained from each of the last six biyearly waves (2007–2017) of the Longitudinal Urban Cohort Ageing Study (LUCAS) in Hamburg, Germany, a prospective observational cohort study of manifold aspects of ageing. Screening of predictor and event variables: depressed mood: one question from the 5-item Mental Health Inventory Screening Test; frailty: LUCAS Functional Ability Index, status ‘frail’; disability: one question on need for human help with basic activities of daily living. Kaplan-Meier curves and Cox’s proportional hazards regression were used for time-to-event analyses with shifting baseline.

Results

Sample size in 2007 was 2012, average age 76.2 years; ±6.5. Main results were as follows: (1) depression significantly increased the hazard of subsequent frailty (HR=1.581; 95% CI 1.257 to 1.988; p<0.001); (2) frailty significantly increased the hazard of subsequent depression (HR=2.324; 95% CI 1.703 to 3.172; p<0.001); (3) depression significantly increased the hazard of subsequent disability (HR=2.589; 95% CI 1.885 to 3.557; p<0.001) and (4) disability did not significantly increase the hazard of subsequent depression (HR=1.540; 95% CI 0.917 to 2.579; p=0.102).

Conclusion

Our results suggest an interdependence of the processes of depression and frailty/disability rather than unidirectional dependencies. These observable processes may be representative of underlying unobservable profound life changes. Obviously, there is a need for early screening to initiate appropriate interventions.

Psychosocial resources related to survival among non-robust community-dwelling older people: an 18-year follow-up study

Aim

To investigate whether psychosocial resources are associated with survival among non-robust community-dwelling older Finnish people during an 18-year follow-up.

Findings

Psychosocial resources, such as good self-rated health and regularly visiting other people, were significantly associated with better survival of non-robust older people.

Message

It is important to focus also on psychological well-being, together with physical activity and nutrition, of frail older people to remain or promoting their capacity.

Purpose

Psychosocial resources have been considered to be associated with survival among frail older adults but the evidence is scarce. The aim was to investigate whether psychosocial resources are related to survival among non-robust community-dwelling older people.

Methods

This is a prospective study with 10- and 18-year follow-ups. Participants were 909 non-robust (according to Rockwood’s Frailty Index) older community-dwellers in Finland. Psychosocial resources were measured with living circumstances, education, satisfaction with friendship and life, visiting other people, being visited by other people, having someone to talk to, having someone who helps, self-rated health (SRH) and hopefulness about the future. To assess the association of psychosocial resources for survival, Cox regression analyses was used.

Results

Visiting other people more often than once a week compared to that of less than once a week (hazard ratio 0.61 [95% confidence interval 0.44–0.85], p = 0.003 in 10-year follow-up; 0.77 [0.62–0.95], p = 0.014 in 18-year follow-up) and good SRH compared to poor SRH (0.65 [0.44–0.97], p = 0.032; 0.68 [0.52–0.90], p = 0.007, respectively) were associated with better survival in both follow-ups. Visiting other people once a week (compared to that of less than once a week) (0.77 [0.62–0.95], p = 0.014) was only associated with better 18-year survival.

Conclusions

Psychosocial resources, such as regularly visiting other people and good self-rated health, seem to be associated with better survival among non-robust community-dwelling Finnish older people. This underlines the importance of focusing also on psychosocial well-being of frail older subjects to remain or promote their resilience.

Older adults' understandings and perspectives on frailty in community and residential aged care: an interpretive description

OBJECTIVES

Despite growing interest in frailty as a significant public health challenge, comparatively little is known about how older adults perceive and experience frailty, limiting the effectiveness of strategies to improve frailty management and prevention. The objective of this study was to understand how older people, including frail older persons in residential aged care, perceive and understand frailty through an interpretive-descriptive qualitative study.

SETTING

Aged care facility, community-based university for older persons and an aged care auxiliary care group in a large metropolitan centre in South Australia.

PARTICIPANTS

39 non-frail, prefrail, frail and very frail South Australian older adults.

METHODS

Seven focus groups were conducted. Participants completed one of two frailty instruments depending on setting and indicated whether they self-identified as frail. Data were analysed inductively and thematically by two independent investigators.

RESULTS

Frailty was described according to three schemas of (1) the old and frail: a static state near the end of life; (2) frailty at any age: a disability model; and (3) frailty as a loss of independence: control, actions and identity. In addition, a theme was identifying linking mindset, cognition and emotion to frailty. The term frailty was viewed negatively and was often implicated with personal choice. There was little correlation between frailty assessments and whether participants self-identified as frail.

CONCLUSIONS

Aside from a disability model, views of frailty as unmodifiable permeated older persons' diverse perspectives on frailty and are likely to impact health behaviours. To our knowledge, this is among the largest qualitative studies examining consumer perceptions of frailty and contributes a clinically relevant schema linking age, prevention and modifiability from a consumer perspective.

"There's More to Frail than That": Older New Zealanders and Health Professionals Talk about Frailty

There is general agreement that frailty is common and important in later life, but there is less agreement about what frailty is. Little is known about the extent to which practicing health professionals and older people hold a mutual understanding of frailty. Focus groups were held to engage older people and health professionals in discussion about what made them think that someone was frail. Eighteen older people took part across three focus groups, and se'venteen health professionals took part across another three focus groups. Both the health professionals and the older people talked about the experience of frailty as an interplay of physical, psychological, and social dimensions. Older people with frailty were seen as needing help and being vulnerable to adverse outcomes, but accepting help was positioned by older people as an adaptive choice. The experience of frailty was described as being mediated by the individual's psychological mindset, highlighting the importance of approaches that recognise strengths and resilience. A broader and more balanced understanding of frailty may help create more rounded and appropriate approaches to assessment and management.

Attitudes towards frailty assessment in clinical practice among psychiatrists in the UK

Purpose

Although there is substantial evidence about the association between frailty and mental illnesses in older people, there is currently little evidence about how this is integrated into psychiatric clinical practice. The purpose of this paper is to explore the attitudes of a sample of psychiatrists in the UK about the concept and assessment of frailty in their clinical practice.

Design/methodology/approach

This research used a qualitative approach with semi-structured interviews. Interview schedules and transcripts were analysed using thematic analysis. NVivo software and an audit trail were used for the data analysis.

Findings

There were ten respondents (all psychiatrists) in this study. From the interviews, it appeared that some respondents were not be fully familiar with existing concepts of frailty. However, from their perspectives, frailty appeared to be multidimensional, reversible and for some could be enhanced by older people’s ability. Negative stereotypes of being frail could undermine the accessibility to appropriate assessment and care. Existing multidisciplinary assessments, with some adjustments to the particular needs of psychiatric patients, can be used to establish a frailty index.

Originality/value

The concept of frailty, especially those concerning its multidimensional and homeostatic nature, should be further examined to make it more applicable to psychiatric practice. Without much more effort, frailty could be assessed within current psychiatric practices. This could constitute a care plan tailored for frail people with a psychiatric illness, so as to improve the outcomes of their treatment and quality of life.

Quality of life is substantially worse for community-dwelling older people living with frailty: systematic review and meta-analysis

PURPOSE

Frailty is an important predictor of adverse health events in older people, and improving quality of life (QOL) is increasingly recognised as a focus for services in this population. This systematic review synthesised evidence of the relationship between frailty and QOL in community-dwelling older people, with an emphasis on how this relationship varied across QOL domains.

METHODS

We conducted a systematic review with meta-analysis. We searched five databases for reports of QOL in older people with frailty and included studies based on pre-defined criteria. We conducted meta-analyses comparing "frail" and "not frail" groups for each QOL scale where data were available. We compared pooled results to distribution-based and known-group differences to enhance interpretation. We summarised reported cross-sectional and longitudinal analyses.

RESULTS

Twenty-two studies (24,419 participants) were included. There were medium or larger standardised mean differences for 24 of 31 QOL scales between frail and not frail groups, with worse QOL for frail groups. These scales encompassed constructs of health-related quality of life as well as psychological and subjective well-being. There were similar findings from mean difference meta-analyses and within-study analyses.

CONCLUSIONS

The association between frailty and lower QOL across a range of constructs is clear and often substantial. Future research should establish whether causal mechanisms link the constructs, which aspects of QOL are most important to older people with frailty, and investigate their tractability. Services focused on measuring and improving QOL for older people with frailty should be introduced.

New horizons in frailty: the contingent, the existential and the clinical

In the past decade, frailty research has focused on refinement of biomedical tools and operationalisations, potentially introducing a reductionist approach. This article suggests that a new horizon in frailty lies in a more holistic approach to health and illness in old age. This would build on approaches that view healthy ageing in terms of functionality, in the sense of intrinsic capacity in interplay with social environment, whilst also emphasising positive attributes. Within this framework, frailty is conceptualised as originating as much in the social as in the biological domain; as co-existing with positive attributes and resilience, and as situated on a continuum with health and illness. Relatedly, social science-based studies involving interviews with, and observations of, frail, older people indicate that the social and biographical context in which frailty arises might be more impactful on the subsequent frailty trajectory than the health crisis which precipitates it. For these reasons, the article suggests that interpretive methodologies, derived from the social sciences and humanities, will be of particular use to the geriatrician in understanding health, illness and frailty from the perspective of the older person. These may be included in a toolkit with the purpose of identifying how biological and social factors jointly underpin the fluctuations of frailty and in designing interventions accordingly. Such an approach will bring clinical approaches closer to the views and experiences of older people who live with frailty, as well as to the holistic traditions of geriatric medicine itself.

Becoming frail: a major turning point in patients' life course

BACKGROUND

The frailty concept requires that practices should be adapted to meet the challenge of dependence. The GP is in the front line of management of frail elderly patients.

OBJECTIVES

To explore the perception of elderly persons of the term and concept of frailty and to understand their perception of the risk of loss of independence.

METHODS

Two qualitative studies by individual interviews in the homes of elderly persons identified as potentially frail by their GP, or diagnosed as frail and at risk of loss of independence. The sampling was theoretical. The analysis was carried out using an inductive approach following the phases of thematic analysis. The researchers used triangulation and collection was concluded when theoretical saturation had been reached.

RESULTS

The concept of frailty was seen as forming an integral part of physiological ageing and appeared to be irreversible. The term of frailty had a negative connotation. The physical, cognitive and psychological components of frailty were present in the participants' discourse. Nutritional and sensory components were less present. Frailty due to inappropriate medication was not cited. Seven risk factors for loss of independence were identified: social isolation, poor physical health, poor mental health, loss of mobility, unsuitable living conditions, unsuitable environment, and low resources.

CONCLUSIONS

Becoming frail is a major turning point in patients' life course. Coordinated multiprofessional management that takes account of patients' perceptions could help in negotiating a feasible care plan adapted to the patient's needs.

Frailty: an in-depth qualitative study exploring the views of community care staff

Background

Frailty is seen across various health and social care settings. However, little is known about how healthcare professionals, particularly those who provide care for older adults living in the community view frailty. There is also a dearth of information about the extent to which a shared understanding of frailty exists across the various disciplines of care. Such an understanding is crucial across care professionals as it ensures consistent assessment of frailty and facilitates interdisciplinary working/collaboration which is a key component in the management of frailty. This study aimed to explore: (i) how community care staff from various specialties viewed frailty; (ii) whether they had a shared understanding; and (iii) how they assessed frailty in everyday practice.

Methods

Semi-structured interviews were conducted with a purposive sample of 22 community care staff from seven specialties, namely: healthcare assistants, therapy assistants, psychiatric nurses, general nurses, occupational therapists, physiotherapists and social workers, recruited from four neighbourhood teams across Cambridgeshire, England. Interviews were analysed thematically.

Results

There was a shared narrative among participants that frailty is an umbrella term that encompasses interacting physical, mental health and psychological, social, environmental, and economic factors. However, various specialities emphasised the role of specific facets of the frailty umbrella. The assessment and management of frailty was said to require a holistic approach facilitated by interdisciplinary working. Participants voiced a need for interdisciplinary training on frailty, and frailty tools that facilitate peer-learning, a shared understanding of frailty, and consistent assessment of frailty within and across specialities.

Conclusions

These findings underscore the need to: (i) move beyond biomedical descriptions of frailty; (ii) further explore the interacting nature of the various components of the frailty umbrella, particularly the role of modifiable factors such as psychological and socioeconomic resilience; (iii) care for frail older adults using holistic, interdisciplinary approaches; and (iv) promote interdisciplinary training around frailty and frailty tools to facilitate a shared understanding and consistent assessment of frailty within and across specialities.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1069-3) contains supplementary material, which is available to authorized users.

Assessing Frailty in Chinese Nursing Home Older Adults: A Comparison between the Frail-NH Scale and Frailty Index

OBJECTIVE

(1) To establish appropriate FRAIL-NH cutoff points in nursing homes in Mainland China; (2) To compare the FRAIL-NH scale and Frailty Index in assessing frailty prevalence and associated factors in nursing homes.

DESIGN

A cross-sectional study.

SETTING

Six nursing homes in Changsha, China.

PARTICIPANTS

A total of 302 residents aged 60 years or older (mean aged 82.71±8.49, 71.2% female).

MEASUREMENTS

Frailty was assessed using the 34-item Frailty Index and the FRAIL-NH scale.

RESULTS

The appropriate FRAIL-NH cutoff points to classify frail status and frailest status were 1.5 (87.6% sensitivity, 63.3% specificity) and 7.5 (94.1% sensitivity, 73.4% specificity), respectively. Based on the FRAIL-NH and Frailty Index, 69.5% (48% for frail and 21.5% for frailest), and 66.5% (60.9% for frail and 5.6% for frailest) of residents were at risk of frailty, respectively. There was no statistically significant difference in the total frailty prevalence assessed by FRAIL-NH and Frailty Index (χ2=0.617, P=0.432). The FRAIL-NH Scale is significantly associated with the Frailty Index (correlation coefficient (r) = 0.74, P < 0.001), but there was a Kappa agreement of 0.39 for frailty classification between the FRAIL-NH and Frailty Index, with the Frailty Index classifying a larger number of individuals as frail. When using FRAIL-NH scale, disease and self-reported health status were associated with frail and frailest status while age was just associated with frailest status. regarding the Frailty Index, age, diseases, medications and self-reported health status were associated with frail and frailest status.

CONCLUSION

The FRAIL-NH is a simple and effective tool to assess the overall frailty rate in nursing homes, and the Frailty Index may be more suitable capturing the multidimensionality of frailty at an individual level. Careful consideration in the selection of a frailty instrument, based on the intended purpose, is necessary.

The emergence and utilisation of frailty in the United Kingdom: a contemporary biopolitical practice

Frailty has recently emerged as a dominant concept against a backdrop of media and governmental narratives that frame the growing ageing population as an economic threat to the current configuration of health care in the United Kingdom (UK). Despite frailty's popularity amongst geriatricians and policy makers, the concept faces resistance from other health-care professionals and older people themselves. This paper draws on the Foucauldian idea of biopower; by suggesting that the contemporary emergence and utilisation of frailty represents a biopolitical practice a number or critical observations are made. First, despite biomedical experts acknowledging ambiguities in the definition of frailty, the concept is presented as a truth discourse. This is driven by the ability of frailty measurements to predict risk of costly adverse outcomes; the capability of frailty scores to enumerate complex needs; and the scientific legitimacy frailty affords to geriatric medicine. Consequently, frailty has become pervasive, knowable and measurable. Second, the routine delineation between frail and robust objectifies older people, and can be said to benefit those making the diagnosis over those being labelled frail, with the latter becoming disempowered. Last, studies show that frailty is associated with increasing wealth inequalities in the UK; however, experts’ suggested management of frailty shifts the focus of responsibility away from ideologically driven structural inequalities towards the frail older person, attempting to encourage individuals to modify lifestyle choices. This neglects the association between lifestyle opportunities and socio-economic deprivation, and the impact of long-term poverty on health. These observations, set against the contemporary political climate of economic austerity, cuts to public services and rationalisation of health resources, bring the urgency of a critical consideration of frailty to the fore.

"She doesn't want to go to hospital. That's one thing she hates": Collective performativity in avoidable nursing home to hospital transfers

Older people who live with a combination of conditions experience fluctuations over time, which others may interpret as a need for medical attention. For some nursing home residents, this results in transitions in and out of hospital. Such transfers may be arranged without expectation of improved quality of life, can be associated with significant morbidity and mortality, and may preclude end-of-life preferences. Factors affecting avoidable hospitalization for nursing home residents are not well understood. I aim to explore potential drivers, moving beyond deficit explanations relating to funding, training, and resources. I use a framework of analysis that firstly considers medicalization of frailty, as a state of vulnerability that provides focus for others' action. I then draw on Judith Butler's theory of performativity, to explore nursing homes as sites of identity work for staff, residents and families. I consider ways subjectivities can be effected through reiterative practice that is compelled by normative conventions. Trouble may arise when citational practice of health care staff, and performative acquiescence of residents and families, culminates in an inevitability of hospitalization when navigating grey areas of assumed clinical risk. Principles of coproduction could present a disruptive opening, to rework power asymmetries, and move toward aspirations for residents and their relatives to be at the centre of decisions about care.

Disorderly Households, Self-Presentation, and Mortality: Evidence From a National Study of Older Adults

This article examines whether disorderly household conditions and bodily self-presentation predict mortality, above and beyond four sets of variables conceptually linked to both death and disorder. Data come from 2005/2006 and 2010/2011 waves of the National Social Life, Health, and Aging Project. We used naturalistic observation of respondents' homes and bodies, along with a diverse range of additional covariates, to predict probability of death. Older adults living in disorderly households were at highest risk of death over 5 years, primarily because they confronted high levels of frailty. Disorderly bodily self-presentation was also related to mortality risk, but this association could be only partially explained by demographic factors, health conditions, frailty, and low social connectedness. Findings suggest that disorder in the residential context-dress and hygiene in particular-is a strong predictor of mortality. Support providers should be mindful of changes in bodily presentation among community-dwelling older adults.

Frailty and quality of life in elderly primary health care users

OBJECTIVE

to investigate the association between physical frailty and quality of life in elderly users of primary health care in the capital of the state of Paraná.

METHOD

a cross-sectional, quantitative study with 203 elders. Data collected included: physical activity questionnaires, weight loss, fatigue/exhaustion, quality of life, performance of gait speed tests, and handgrip strength.

RESULTS

of the 203 older adults, 115 were pre-frail, 49 were non-frail, and 39 were frail, with a significant association with functional capacity and quality of life in all groups. The dimensions resulting from physical aspects, pain, and vitality were associated with those that were non-frail.

CONCLUSION

in this study, frailty syndrome was inversely proportional to the quality of life, and significantly associated with functional capacity of older adults. Physical frailty is a manageable condition which can be targeted through geriatric nursing interventions.

Understanding frailty: meanings and beliefs about screening and prevention across key stakeholder groups in Europe

Innovative methods to manage frailty are critical to managing the needs of an ageing population. Evidence suggests there are opportunities to reverse or prevent frailty through early intervention. However, little is known about older adults’, families’ and practitioners’ beliefs about the malleability of frailty. This study examined European stakeholders’ accounts of the acceptability and feasibility of frailty screening and prevention to inform future intervention development. Semi-structured focus groups and individual interviews were conducted in three European Union countries (Italy, Poland and the United Kingdom) with key stakeholders – frail and non-frail older adults, family care-givers, and health and social care professionals. Thematic analysis identified four themes: synchronicity between the physical and the psychological in frailty, living with frailty in the social world, the need for a new kind of care, and screening for and preventing frailty. Findings emphasised the need for a holistic approach to frailty care and early intervention. Integrated care services and advocacy were important in the organisation of care. Central to all stakeholders was the significance of the psychological and social alongside the physical elements of frailty and frailty prevention. Support and care for older adults and their family care-givers needs to be accessible and co-ordinated. Interventions to prevent frailty must encompass a social dimension to help older adults maintain a sense of self while building physical and psychological resilience.

The use of case management for community-dwelling older people: the effects on loneliness, symptoms of depression and life satisfaction in a randomised controlled trial

AIM

To investigate the effects of a case management intervention for community-dwelling frail older people, with functional dependency and repeated contacts with the healthcare services, focusing on loneliness, depressive symptoms and life satisfaction.

DESIGN

A two-armed, nonblinded, randomised control trial with repeated follow-ups, of N = 153 participants at baseline allocated to an intervention (n = 80) and control (n = 73) group.

METHOD

Inclusion criteria were the following: ≥65 years of age, living in ordinary housing, in need of assistance in two or more self-reported activities of daily living, having at least two hospital admissions or at least four visits in outpatient care 12 months prior to enrolment. Case managers (nurses and physiotherapists) provided an intervention of general case management, general information, specific information and continuity and safety. The intervention ranged over 12 months with one or more home visit(s) being conducted per month. An intention-to-treat analysis was applied for the primary outcomes of loneliness, depressive symptoms and life satisfaction, along with complete case and sensitivity analyses.

RESULTS

During the trial period n = 12 died and n = 33 dropped out. No significant difference was found between the groups at baseline regarding sociodemographic characteristics, subjective health or primary outcomes. The intention-to-treat analysis did not result in any significant effects for the primary outcomes at any of the follow-ups (6 and 12 months). The complete case analysis resulted in a significant difference in favour of the intervention regarding loneliness (RR = 0.49, p = 0.028) and life satisfaction (ES = 0.41, p = 0.028) at 6 months and for depressive symptoms (ES = 0.47, p = 0.035) at 12 months.

CONCLUSIONS

The use of case management for frail older people did not result in clear favourable effects for the primary outcomes. However, the study indicates that case management may be beneficial in terms of these outcomes. Due to the complexity of the outcomes, an elaboration of the components and assessments is suggested.

Impact of a lay-led home-based intervention programme on quality of life in community-dwelling pre-frail and frail older adults: a randomized controlled trial

BACKGROUND

Due to the demographic ageing process and the increasing number of pre-frail and frail individuals, new lifestyle interventions to enhance the quality of life (QoL) in community-dwelling older adults are necessary. Therefore, we performed a randomised controlled trial (RCT) to compare effects of a lay-led home-based physical and nutritional intervention programme with social support alone on different QoL domains in community-dwelling pre-frail and frail older adults.

METHODS

In this analysis within a RCT (12 weeks), lay volunteers visited one-on-one pre-frail or frail older adults at home twice a week. Participants in the physical training and nutritional intervention (PTN) group performed six strength exercises and discussed main nutritional issues during each visit. The social support (SOSU) group received home visits twice a week for social exchanges. The QoL was assessed with the WHOQOL-BREF and the WHOQOL-OLD instruments. Analyses of covariance (ANCOVA) were used to examine differences between groups with baseline values as the covariate. Changes within groups were assessed with paired t-tests.

RESULTS

Eighty participants (n = 39 in the PTN group and n = 41 in the SOSU group) were included. No significant differences were found between the two groups except in past, present and future activities domain [β = 3.66 (95% confidence interval 0.13 to 7.18)] in favour of the PTN group. However, there was some evidence of greater within group improvements in the PTN group particularly in overall QoL, social relations and social participation. In the SOSU group, no significant effect was observed in any QoL domain.

CONCLUSION

A combination of a home-based physical and nutritional intervention was not more effective compared to social support alone, on QoL in community-dwelling pre-frail and frail older adults. However, the small but significant improvement within the PTN group suggests that a home-based physical and nutritional intervention delivered by volunteers may influence the QoL in a positive way.

TRIAL REGISTRATION

The study protocol was registered on 6 November 2013 at ClinicalTrials.gov (identifier: NCT01991639 ).

Older persons' existential loneliness, as interpreted by their significant others - an interview study

BACKGROUND

In order to better understand people in demanding medical situations, an awareness of existential concerns is important. Studies performed over the last twenty years conclude that when dying and death come closer, as in the case with older people who are stricken by infirmity and diseases, existential concerns will come to the fore. However, studies concerning experiences of existential loneliness (EL) are sparse and, in addition, there is no clear definition of EL. EL is described as a complex phenomenon and referred to as a condition of life, an experience, and a process of inner growth. Listening to someone who knows the older person well, as significant others often do, may be one way of learning more about EL.

METHODS

This study is part of a larger research project on EL, the LONE study, where EL is explored through interviews with frail older people, their significant others and health care professionals. The aim of this study was to explore frail older (>75) persons' EL, as interpreted by their significant others. The study is qualitative and based on eighteen narrative interviews with nineteen significant others of older persons. The data was analysed using Hsieh and Shannon's conventional content analysis.

RESULTS

According to the interpretation of significant others, the older persons experience EL (1) when they are increasingly limited in body and space, (2) when they are in a process of disconnecting, and (3) when they are disconnected from the outside world.

CONCLUSION

The result can be understood as if the frail older person is in a process of letting go of life. This process involves the body, in that the older person is increasingly limited in his/her physical abilities. The older person's long-term relationships are gradually lost, and finally the process entails the older person's increasingly withdrawing into him- or herself and turning off the outside world. The result of this study is consistent with previous research that has shown that EL is a complex phenomenon, but the implications of this research include a deepened understanding of EL. In addition, the study highlights the interpretations of significant others.

Integrated information for integrated care in the general practice setting in Italy: using social network analysis to go beyond the diagnosis of frailty in the elderly

BACKGROUND

Frailty has been defined in different ways and several diagnostic tools exist, but most of them are not applicable in routine primary care. Nonetheless, general practitioners (GPs) have a natural advantage in identifying frailty, due to their continued access to patients, patient-centered approach and training. GPs have also an advantage in conducting population-based evaluation as consequence of their role of gatekeepers of the health care system. This paper aims to identify those socio-demographic and clinical profiles and the relative information sources that, from the GPs' perspective, act as frailty markers, not solely as a diagnosis of state but as the ability to identify a patient's trajectory, over time, through the aging process.

METHODS

This study was performed as a survey within a population aged 75 and over, attending 148 GPs in Italy. A total of 23,996 patients were classified by GPs in distinct frailty status, without the use of a specific evaluation tool, but only referring to general indications. Co-morbidity was objectively assessed by a record-linkage with previous hospitalizations, in order to assess the occurrence of previous illnesses that could be associated with the likelihood of being identified as frails or at risk. The methodological approach is based on social network analysis (SNA), suited to explore relational aspects of complex phenomena.

RESULTS

Our findings reveal that GPs are able to perform low cost population-based evaluation, by exploiting the advantages of their approach to patients, combined with the information derived from their daily practice and from other sources currently available.

CONCLUSION

We believe that informative integration among different sources of available data can provide a comprehensive picture of the health state of patients in a shorter time and at lower cost. The identification of limited patient trajectories based on these observations can enable the development of critical biomarkers/diagnostics and prognostic indicators that will enhance patient care and potentially reduce inappropriate healthcare use. We also believe that network analysis is an extremely flexible research tool and a rich theoretical paradigm, and it may be used in the healthcare planning.

The relevance of memory sensitivity for psychological well-being in aging

PURPOSE

In the present study, we investigated the relationship between memory sensitivity, which describes a positive attitude to autobiographical memory and the presence of behaviors devoted to saving memories of the personal past, and psychological well-being; in particular, we tested whether their relationship would change across age groups.

METHODS

Three hundred eighteen participants, divided in four groups: young to middle-aged adults (20-55 years old), young-old adults (65-74 years old), old adults (75-84 years old), and old-old adults (85-97 years old), completed questionnaires on their memory sensitivity and psychological well-being.

RESULTS

Memory sensitivity slightly decreased with age and had a positive relationship with psychological well-being that was critically moderated by age. Specifically, the relationship between memory sensitivity and psychological well-being became increasingly stronger as age increased.

CONCLUSIONS

While memory sensitivity may have little or no particular relevance in the case of young to middle-aged adults, it has an increasingly important positive relationship with psychological well-being at later age. It is thus suggested that memory sensitivity represents a dimension that should be considered in the study and interventions on quality of life in the elderly population.