Validation of the frail scale in a cohort of older Australian women

Psychometric Properties of the FRAIL Scale for Frailty Screening: A Scoping Review

OBJECTIVES

The aim of this study was to identify and map the available psychometric evidence of the FRAIL scale to screen frailty among older adults.

DESIGN

Scoping review of published articles on 9 databases (PubMed, Scopus, Web of Science, CINAHL, Cochrane, Embase, PsycINFO, VHL Regional Portal, and Epistemonikos) and 8 gray literature sources.

SETTING AND PARTICIPANTS

Studies in adults or older adults, in both inpatient and outpatient settings (without context restrictions).

METHODS

Cross-cultural adaptations, validity and reliability evidence studies, whose main objective was to develop and/or validate and/or culturally adapt the FRAIL Scale to assess frailty in adults or older adults, published since 2007 were included in this scoping review. The databases were searched between February and March 2023.The JBI methodology for scoping reviews was used to guide the process. The protocol of this study was registered on the Open Science Framework platform.

RESULTS

Of the 1031 records found during the search, 40 articles that met the established criteria for analysis were included. Nearly 1 in 10 countries worldwide (11.9%) have psychometric evidence regarding this scale. Ten studies were identified with the goal of cross-cultural adaptation and/or validation in a different cultural context for the first time. Twenty-one of 40 studies used Morley 2012 operationalization of FRAIL Scale criteria. Thirty-nine studies provided evidence of associations with other variables. The rest of the evidence for content, internal structure, response processes, and reliability was only evaluated in cross-cultural adaptation studies, with limitations.

CONCLUSIONS AND IMPLICATIONS

In conclusion, there is some evidence of validity for FRAIL Scale; nevertheless, studies are needed to adapt the scale to new cultures, using rigorous Cross-Cultural Adaptation processes, and to provide new evidence of validity and reliability, to strengthen and consolidate the body of knowledge for its application to various patient groups and context.

Health-related quality of life measures provide information on the contributors, components, and consequences of frailty in HIV: a systematic mapping review

PURPOSE

Frailty in HIV is extensively explored in epidemiological and clinical studies; it is infrequently assessed as an outcome in routine care. The focus on health-related quality of life (HRQL) measures in HIV presents a unique opportunity to understand frailty at a larger scale. The objective was to identify the extent to which generic and HIV-related HRQL measures capture information relevant to frailty.

METHODS

A systematic mapping review using directed and summative content analyses was conducted. An online search in PubMed/Medline identified publications on frailty indices and generic and HIV-related HRQL measures. Directed content analysis involved identifying contributors, components, and consequences of frailty from the frailty indices based on the International Classification of Functioning, Disability, and Health framework. Summative content analysis summarized the results numerically.

RESULTS

Electronic and hand search identified 447 review publications for frailty indices; nine reviews that included a total of 135 unique frailty indices. The search for generic and HIV-related HRQL measures identified 2008 records; five reviews that identified 35 HRQL measures (HIV-specific: 17; generic: 18). Of the 135 frailty indices, 88 cover more than one frailty dimension and 47 cover only physical frailty. Contributors to frailty, like sensory symptoms and nutrition, are extensively covered. Components of frailty such as physical capacity, cognitive ability, and mood are also extensively covered. Consequences of frailty namely self-rated health, falls, hospitalization, and health services utilization are incomprehensively covered. HRQL measures are informative for contributing factors, components of frailty, and a consequence of frailty.

CONCLUSION

HRQL items and measures show a strong potential to operationalize multidimensional frailty and physical frailty. The study suggests that these measures, connected to evidence-based interventions, could be pivotal in directing resources toward vulnerable populations to mitigate the onset of frailty.

Prevalence and modifiable risk factors of cognitive frailty in patients with chronic heart failure in China: a cross-sectional study

BACKGROUND

Cognitive frailty (CF) is currently a significant issue, and most of the associated factors discovered in current studies are not modifiable. Therefore, it is crucial to identify modifiable risk factors that can be targeted for interventions in patients with chronic heart failure (CHF). This study aimed to investigate the prevalence and modifiable risk factors of CF in CHF patients in China.

METHODS

In this cross-sectional study, we sequentially enrolled patients diagnosed with CHF. CF served as the dependent variable, assessed through the Montreal Cognitive Assessment (MoCA) Scale and the FRAIL Scale. The independent variable questionnaire encompassed various components, including general demographic information, the Social Support Rating Scale (SSRS), the Simplified Nutrition Appetite Questionnaire (SNAQ), the Hamilton Depression Scale (HAMD), the Hamilton Anxiety Scale (HAMA), and the Minnesota Living with Heart Failure Questionnaire (MLHFQ). Logistic regression analysis was employed to identify independent factors contributing to CF.

RESULTS

A total of 271 patients with CHF were included in the study. The overall prevalence of CF was found to be 49.4%, with 28.8% of patients exhibiting potentially reversible cognitive frailty and 20.7% showing reversible cognitive frailty. Among middle-young CHF patients, 10.7% had reversible cognitive frailty and 6.4% had potentially reversible cognitive frailty, with a prevalence of CF at 17.1%. Logistic regression analysis revealed that body mass index (OR = 0.826, 95%CI = 0.726-0.938), blood pressure level (OR = 2.323, 95%CI = 1.105-4.882), nutrition status (OR = 0.820, 95%CI = 0.671-0.979), and social support (OR = 0.745, 95%CI = 0.659-0.842) were independent factors associated with CF (p < 0.05).

CONCLUSIONS

We observed a relatively high prevalence of CF among Chinese patients diagnosed with CHF. Many factors including BMI, blood pressure level, nutrition status, and social support emerging as modifiable risk factors associated with CF. We propose conducting clinical trials to assess the impact of modifying these risk factors. The outcomes of this study offer valuable insights for healthcare professionals, guiding them in implementing effective measures to improve the CF status in CHF patients during clinical practice.

Diagnostic accuracy of the FRAIL scale for frailty screening in community-dwelling older adults with diabetes: A cross-sectional study

There is limited evidence on the diagnostic accuracy of the FRAIL scale in community-dwelling older adults with diabetes. This study aimed to validate the diagnostic accuracy and determine the optimal cutoff point of the FRAIL scale in community-dwelling older adults with diabetes using the Fried Frailty Phenotype as the reference standard. A total of 489 community-dwelling older adults with diabetes aged 60 or above were recruited in this cross-sectional study. The FRAIL scale showed good diagnostic accuracy for frailty screening. The optimal cutoff point for frailty screening in older adults with diabetes was 2. The agreement between the FRAIL scale and the Fried Frailty Phenotype was substantial. The FRAIL scale classified more participants as frail (29.24%) than the Fried Frailty Phenotype (22.09%). These findings provide evidence that the FRAIL scale is a valid tool that can be applied to community-dwelling older adults with diabetes.

Frailty Syndrome as a Transition from Compensation to Decompensation: Application to the Biomechanical Regulation of Gait

Most gait parameters decrease with age and are even more importantly reduced with frailty. However, other gait parameters exhibit different or even opposite trends for aging and frailty, and the underlying reason is unclear. Literature focuses either on aging, or on frailty, and a comprehensive understanding of how biomechanical gait regulation evolves with aging and with frailty seems to be lacking. We monitored gait dynamics in young adults (19-29 years, n = 27, 59% women), middle-aged adults (30-59 years, n = 16, 62% women), and non-frail (>60 years, n = 15, 33% women) and frail older adults (>60 years, n = 31, 71% women) during a 160 m walking test using the triaxial accelerometer of the Zephyr Bioharness 3.0 device (Zephyr Technology, Annapolis, MD, USA). Frailty was evaluated using the Frail Scale (FS) and the Clinical Frailty Scale (CFS). We found that in non-frail older adults, certain gait parameters, such as cadence, were increased, whereas other parameters, such as step length, were decreased, and gait speed is maintained. Conversely, in frail older adults, all gait parameters, including gait speed, were decreased. Our interpretation is that non-frail older adults compensate for a decreased step length with an increased cadence to maintain a functional gait speed, whereas frail older adults decompensate and consequently walk with a characteristic decreased gait speed. We quantified compensation and decompensation on a continuous scale using ratios of the compensated parameter with respect to the corresponding compensating parameter. Compensation and decompensation are general medical concepts that can be applied and quantified for many, if not all, biomechanical and physiological regulatory mechanisms of the human body. This may allow for a new research strategy to quantify both aging and frailty in a systemic and dynamic way.

Association Between the FRAIL Scale and Postoperative Complications in Older Surgical Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Several frailty screening tools have been shown to predict mortality and complications after surgery. However, these tools were developed for in-person evaluation and cannot be used during virtual assessments before surgery. The FRAIL (fatigue, resistance, ambulation, illness, and loss of weight) scale is a brief assessment that can potentially be conducted virtually or self-administered, but its association with postoperative outcomes in older surgical patients is unknown. The objective of this systematic review and meta-analysis (SRMA) was to determine whether the FRAIL scale is associated with mortality and postoperative outcomes in older surgical patients.

METHODS

Systematic searches were conducted of multiple literature databases from January 1, 2008, to December 17, 2022, to identify English language studies using the FRAIL scale in surgical patients and reporting mortality and postoperative outcomes, including postoperative complications, postoperative delirium, length of stay, and functional recovery. These databases included Medline, Medline ePubs/In-process citations, Embase, APA (American Psychological Association) PsycInfo, Ovid Emcare Nursing, (all via the Ovid platform), Cumulative Index to Nursing and Allied Health Literature (CINAHL) EbscoHost, the Web of Science (Clarivate Analytics), and Scopus (Elsevier). The risk of bias was assessed using the quality in prognosis studies tool.

RESULTS

A total of 18 studies with 4479 patients were included. Eleven studies reported mortality at varying time points. Eight studies were included in the meta-analysis of mortality. The pooled odds ratio (OR) of 30-day, 6-month, and 1-year mortality for frail patients was 6.62 (95% confidence interval [CI], 2.80-15.61; P < .01), 2.97 (95% CI, 1.54-5.72; P < .01), and 1.54 (95% CI, 0.91-2.58; P = .11), respectively. Frailty was associated with postoperative complications and postoperative delirium, with an OR of 3.11 (95% CI, 2.06-4.68; P < .01) and 2.65 (95% CI, 1.85-3.80; P < .01), respectively. The risk of bias was low in 16 of 18 studies.

CONCLUSIONS

As measured by the FRAIL scale, frailty was associated with 30-day mortality, 6-month mortality, postoperative complications, and postoperative delirium.

Development and validation of risk prediction model for identifying 30-day frailty in older inpatients with undernutrition: A multicenter cohort study

Objective

To develop and externally validate a frailty prediction model integrating physical factors, psychological variables and routine laboratory test parameters to predict the 30-day frailty risk in older adults with undernutrition.

Methods

Based on an ongoing survey of geriatrics syndrome in elder adults across China (SGSE), this prognostic study identified the putative prognostic indicators for predicting the 30-day frailty risk of older adults with undernutrition. Using multivariable logistic regression analysis with backward elimination, the predictive model was subjected to internal (bootstrap) and external validation, and its calibration was evaluated by the calibration slope and its C statistic discriminative ability. The model derivation and model validation cohorts were collected between October 2018 and February 2019 from a prospective, large-scale cohort study of hospitalized older adults in tertiary hospitals in China. The modeling derivation cohort data (n = 2,194) were based on the SGSE data comprising southwest Sichuan Province, northern Beijing municipality, northwest Qinghai Province, northeast Heilongjiang Province, and eastern Zhejiang Province, with SGSE data from Hubei Province used to externally validate the model (validation cohort, n = 648).

Results

The incidence of frailty in the older undernutrition derivation cohort was 13.54% and 13.43% in the validation cohort. The final model developed to estimate the individual predicted risk of 30-day frailty was presented as a regression formula: predicted risk of 30-day frailty = [1/(1+e^-riskscore )], where riskscore = -0.106 + 0.034 × age + 0.796 × sex -0.361 × vision dysfunction + 0.373 × hearing dysfunction + 0.408 × urination dysfunction - 0.012 × ADL + 0.064 × depression - 0.139 × nutritional status - 0.007 × hemoglobin - 0.034 × serum albumin - 0.012 × (male: ADL). Area under the curve (AUC) of 0.71 in the derivation cohort, and discrimination of the model were similar in both cohorts, with a C statistic of nearly 0.7, with excellent calibration of observed and predicted risks.

Conclusion

A new prediction model that quantifies the absolute risk of frailty of older patients suffering from undernutrition was developed and externally validated. Based on physical, psychological, and biological variables, the model provides an important assessment tool to provide different healthcare needs at different times for undernutrition frailty patients.

Clinical trial registration

Chinese Clinical Trial Registry [ChiCTR1800017682].

Cross-cultural adaptation and validation of the geriatric 8 screening tool in Chinese hospitalized older adults with cancer

OBJECTIVES

To translate, cross-culturally adapt, and validate the Geriatric 8 (G8) questionnaire in Chinese hospitalized older adults with cancer.

METHODS

The Chinese version of the G8 (C-G8) was produced following Brislin's guidelines. The psychometric properties of the C-G8 were evaluated among 296 eligible patients.

RESULTS

The content validity index of the C-G8 was 0.8∼1 at the item level and 0.975 at the scale level. The C-G8 identified more frail individuals among these older (>75 years) participants compared to their younger (65∼75 years) counterparts (frailty prevalence: 87.1% vs. 70.9%, P=0.010). The convergent validity of the C-G8 was tested by correlating it with the FRAIL scale (r=-0.592, P<0.001). The C-G8 had a lower internal consistency (Cronbach's α coefficient=0.501) but higher test-retest reliability and inter-rater reliability (intraclass correlation coefficient=0.913 and 0.993, respectively, P<0.001).

CONCLUSIONS

The C-G8 questionnaire presented acceptable validity and reliability and could be used in Chinese hospitalized older adults with cancer.

The Hospital Frailty Risk Score Identifies Fewer Cases of Frailty in a Community-Based Cohort of Older Men Than the FRAIL Scale and Frailty Index

OBJECTIVES

The recently developed Hospital Frailty Risk Score (HFRS) allows ascertainment of frailty from administrative data. We aimed to compare the HFRS against the widely used FRAIL Scale and Frailty Index.

DESIGN

Population-based cohort study linked to Western Australian Hospital Morbidity Data Collection and Death Registrations.

SETTING AND PARTICIPANTS

The Health in Men Study with frailty determined at Wave 2 (2001/2004), mortality in the 1-year period following Wave 2, and disability at Wave 3 (2008). Participants were 4228 community-based men aged ≥75 years, followed until Wave 3.

MEASUREMENTS

We used multivariable regression to determine the association between each frailty measure and outcomes of length of stay (LOS), death, and disability. We also determined if the additional cases of frailty identified by one measure over the other was associated with these outcomes.

RESULTS

Of 4228 men studied, the HFRS (n = 689) identified fewer men as frail than the FRAIL Scale (n = 1648) and Frailty Index (n = 1820). In the fully adjusted models, all 3 frailty measures were associated with longer LOS and mortality, whereas only the FRAIL Scale and Frailty Index were significantly associated with disability. The additional cases of frailty identified by the FRAIL Scale and Frailty Index had longer LOS and greater risks of death and disability. The fully adjusted hazard ratio for death among the additional cases of frailty identified by the FRAIL Scale (compared to being not frail on both HFRS and FRAIL Scale) was 2.14 (95% CI 1.48-3.08).

CONCLUSIONS AND IMPLICATIONS

The HFRS is associated with adverse outcomes. However, it identified approximately 60% fewer men who were frail than the FRAIL Scale and Frailty Index, and the additional cases identified were also at high risks of adverse outcomes. Users of the HFRS should be aware of the differences with other frailty measures.

Risk factors and a nomogram for frailty in Chinese older patients with Alzheimer's disease: A single-center cross-sectional study

This study aimed to determine the risk factors of frailty in Chinese older patients with Alzheimer's disease (AD) and then construct a nomogram for frailty in this population. A total of 205 eligible older AD patients were recruited. Patients' general demographic characteristics were collected through a self-designed questionnaire. A nomogram was constructed for frailty based on the risk factors identified from the multivariate analysis. The discrimination and calibration capabilities of this nomogram were assessed with the C-index and calibration curve, respectively. The results showed that older age, no regular exercise habit, severe cognitive decline, and low social support were identified as important risk factors of frailty in AD patients. The C-index of the nomogram was 0.884 by bootstrapping validation, and the calibration curve of the nomogram showed high coherence between the predicted and actual probabilities of frailty. In conclusion, this nomogram was validated to have favorable discrimination and calibration capabilities.

Chronotropic Response and Heart Rate Variability before and after a 160 m Walking Test in Young, Middle-Aged, Frail, and Non-Frail Older Adults

The frailty syndrome is characterized by a decreased capacity to adequately respond to stressors. One of the most impaired physiological systems is the autonomous nervous system, which can be assessed through heart rate (HR) variability (HRV) analysis. In this article, we studied the chronotropic response (HR and HRV) to a walking test. We also analyzed HRV indices in rest as potential biomarkers of frailty. For this, a 160 m-walking test and two standing rest tests (before and after the walking) were performed by young (19−29 years old, n = 21, 57% women), middle-aged (30−59 years old, n = 16, 62% women), and frail older adults (>60 years old, n = 28, 40% women) and non-frail older adults (>60 years old, n = 15, 71% women), classified with the FRAIL scale and the Clinical Frailty Scale (CFS). Frequency domain parameters better allowed to distinguish between frail and non-frail older adults (low-frequency power LF, high-frequency power HF (nu), LF/HF ratio, and ECG-derived respiration rate EDR). Frail older adults showed an increased HF (nu) and EDR and a reduced LF (nu) and LF/HF compared to non-frail older adults. The increase in HF (nu) could be due to a higher breathing effort. Our results showed that a walk of 160 m is a sufficient cardiovascular stressor to exhibit an attenuated autonomic response in frail older adults. Several HRV indices showed to be potential biomarkers of frailty, being LF (nu) and the time required to reach the maximum HR the best candidates.

Frailty is an independent risk factor for postoperative pulmonary complications in elderly patients undergoing video-assisted thoracoscopic pulmonary resections

BACKGROUND

Although frailty as a common geriatric syndrome is associated with postoperative complications, its relationship with postoperative pulmonary complications (PPCs) following pulmonary resections in elderly patients is unclear.

AIMS

To investigate the relationship between frailty and PPCs in elderly patients undergoing video-assisted thoracoscopic pulmonary resections and explore the effect of the addition of frailty assessment to PPC risk index and ASA on their predictive ability.

METHODS

In a prospective cohort study, we measured frailty status using the FRAIL scale in elderly patients undergoing video-assisted thoracoscopic pulmonary resections. Multivariate analysis was used to identify the relationship between frailty and PPCs. Receiver operating characteristic curves were used to examine the predictive power of frailty and other assessment tools.

RESULTS

227 patients were analyzed in the study. The prevalence of PPCs was 24.7%. Significant differences between patients with and without PPCs were observed in the following aspects: BMI, smoking, COPD, respiratory infection within the last month, FEV1/FVC ratio, creatinine, ASA, frailty and PPC risk index (p < 0.05, respectively). After adjusting for all covariates, frailty was significantly related to PPCs in elderly patients (odds ratio: 6.33, 95% confidence interval: 2.45-16.37). Combined with frailty assessment, the area under the curve for ASA class and PPC risk index was increased to 0.759 (95% CI 0.687-0.831) and 0.821 (95% CI 0.758-0.883).

CONCLUSIONS

Frailty was associated with PPCs in elderly patients undergoing video-assisted thoracoscopic pulmonary resections. Combined with the frailty assessment, the predictive power of the PPC risk index and ASA class was improved.

Kinematic analysis of activities of daily living performance in frail elderly

Background

Frailty is accompanied by limitations of activities of daily living (ADL) and frequently associated with reduced quality of life, institutionalization, and higher health care costs. Despite the importance of ADL performance for the consequence of frailty, movement analyses based on kinematic markers during the performance of complex upper extremity-based manual ADL tasks in frail elderly is still pending.

The main objective of this study was to evaluate if ADL task performance of two different tasks in frail elderlies can be assessed by an activity measurement based on an acceleration sensor integrated into a smartwatch, and further to what degree kinematic parameters would be task independent.

Methods

ADL data was obtained from twenty-seven elderly participants (mean age 81.6 ± 7.0 years) who performed two ADL tasks. Acceleration data of the dominant hand was collected using a smartwatch. Participants were split up in three groups, F (frail, n = 6), P (pre-frail, n = 13) and R (robust, n = 8) according to a frailty screening. A variety of kinematic measures were calculated from the vector product reflecting activity, agility, smoothness, energy, and intensity.

Results

Measures of agility, smoothness, and intensity revealed significant differences between the groups (effect sizes combined over tasks η²_p = 0.18 – 0.26). Smoothness was particularly affected by frailty in the tea making task, while activity, agility, a different smoothness parameter and two intensity measures were related to frailty in the gardening task. Four of nine parameters revealed good reliability over both tasks (r = 0.44 – 0.69). Multiple linear regression for the data combined across tasks showed that only the variability of the magnitude of acceleration peaks (agility) contributed to the prediction of the frailty score (R² = 0.25).

Conclusion

The results demonstrate that ADL task performance can be assessed by smartwatch-based measures and further shows task-independent differences between the three levels of frailty. From the pattern of impaired and preserved performance parameters across the tested tasks, we concluded that in persons with frailty ADL performance was more impaired by physiological deficiencies, i.e., physical power and endurance, than by cognitive functioning or sensorimotor control.

The feasibility and reliability of frailty assessment tools applicable in acute in-hospital trauma patients: A systematic review

BACKGROUND

Assessing frailty in patients with an acute trauma can be challenging. To provide trustworthy results, tools should be feasible and reliable. This systematic review evaluated existing evidence on the feasibility and reliability of frailty assessment tools applied in acute in-hospital trauma patients.

METHODS

A systematic search was conducted in relevant databases until February 2020. Studies evaluating the feasibility and/or reliability of a multidimensional frailty assessment tool used to identify frail trauma patients were identified. The feasibility and reliability results and the risk of bias of included studies were assessed. This study was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and registered in Prospective Register of Systematic Reviews (ID: CRD42020175003).

RESULTS

Nineteen studies evaluating 12 frailty assessment tools were included. The risk of bias of the included studies was fair to good. The most frequently evaluated tool was the Clinical Frailty Scale (CFS) (n = 5). All studies evaluated feasibility in terms of the percentage of patients for whom frailty could be assessed; feasibility was high (median, 97%; range, 49-100%). Other feasibility aspects, including time needed for completion, tool availability and costs, availability of instructions, and necessity of training for users, were hardly reported. Reliability was only assessed in three studies, all evaluating the CFS. The interrater reliability varied between 42% and >90% agreement, with a Krippendorff α of 0.27 to 0.41.

CONCLUSION

Feasibility of most instruments was generally high. Other aspects were hardly reported. Reliability was only evaluated for the CFS with results varying from poor to good. The reliability of frailty assessment tools for acute trauma patients needs further critical evaluation to conclude whether assessment leads to trustworthy results that are useful in clinical practice.

LEVEL OF EVIDENCE

Systematic review, Level II.

Medications use among women with dementia: a cohort study

BACKGROUND

Older population with dementia use huge range of medications. In this study, we aimed to determine the prevalence of commonly used medications a year before and after first recorded dementia diagnosis among older Australian women.

METHODS

The study utilized Australian Longitudinal Study on Women's Health (ALSWH) data from 2090 women with known dementia, linked with administrative health datasets. The Pharmaceutical Benefits Scheme (PBS) data provided detailed information about prescribed medications. We applied latent class analysis (LCA) to the post-dementia data to identify patterns of medication use. Logistic regression model was used to explore the impact of potential predictors for medication utilization.

RESULTS

Antipsychotic use increased from 5% before dementia to 19% after dementia, while antidementia medication use increased from < 1 to 28%. There was a modest increase in benzodiazepines and antidepressants. Post-dementia, four distinct groups were identified using LCA (names based on probabilities of medications use) as: "High Psychotropic-Low Cardiovascular" (16% of the sample); "Moderate Psychotropic-High Cardiovascular" (12%); "Low Psychotropic-High Cardiovascular" (27%); and "Low Psychotropic-Low Cardiovascular" (45%). Living in Residential Aged Care (RAC) and frailty were associated with increased odds of being in the higher psychotropic use groups.

CONCLUSIONS

Substantial utilization of psychotropic medications by older people with dementia indicates a need for a careful review of the use of these medications. Appropriate alternative approaches to the management of dementia should be practiced with a special focus on RAC residents with frailty.

Transitions in the Cognitive Frailty States in Community-Living Older Adults: A 6-Year Prospective Cohort Study

Background: Frailty is a multidimensional concept, including physical, cognitive, social, sensorial, psychological, and nutritional phenotypes. Among these phenotypes, cognitive frailty is the most widely investigated, which is related to many adverse health outcomes in older individuals. Whether cognitive frailty is dynamic or how these frail phenotypes interact remains an open issue. We studied the rate of these changes over time and their associated factors in a 6-year follow-up cohort.

Methods: A total of 426 Chinese community-living older adults in Dujiangyan aged 65 years or older were involved and followed up in three visits 6 years apart. Frailty and cognitive function were assessed using the FRAIL scale and the Mini-Mental State Examination scale. Demographic information, geriatric syndrome, and social interaction status were studied. Rates of transitions in cognitive frailty states and associated risk factors were studied. We used the stepwise logistic regression model to analyze risk factors.

Results: At baseline, 18.8% of participants were only in the physical frailty (PF) or mild cognitive impairment (MCI) group, and 0.09% of participants were in the cognitive frailty group. By the end of 6 years, 62 (14.5%) participants had died, and the rates of only PF or MCI group and cognitive frailty group increased to 36.2 and 3.3%, respectively. Also, 199 (46.7%) participants had deteriorated compared with the baseline. The multivariate regression analysis showed that older (OR = 1.12, 95% CI = 1.07 − 1.16, P < 0.001), smoker (OR = 2.15, 95% CI = 1.37 − 3.39, P = 0.001), poor self-evaluation health status (OR = 1.93, 95% CI = 1.06 − 3.51, P = 0.033), and malnutrition (OR = 2.07, 95% CI = 1.21 − 3.52, P = 0.008) were risk factors for worsening, whereas willing to make new friends (OR = 0.61, 95% CI = 0.38 − 0.96, P = 0.032) was associated with 39% lower chance of deterioration.

Conclusion: Cognitive frailty is a dynamically changing state, where transitions may be influenced by multidimensions. Multidimensional monitoring of a wide range of events occurring in aging may be the best way to act early. We hope our study may serve as a starting point for redefining the definition of cognitive frailty by covering different frailty domains.

Polypharmacy trajectories among older women with and without dementia: A longitudinal cohort study

Background

Objective

Method

Results

Conclusion

Frailty and potentially inappropriate medications using the 2019 Beers Criteria: findings from the Australian Longitudinal Study on Women's Health (ALSWH)

BACKGROUND

Frailty is an essential consideration with potentially inappropriate medications (PIMs), especially among older women.

AIMS

This study determined the use of potentially inappropriate medications according to frailty status using the Beers Criteria 2019, identified medications that should be flagged as potentially inappropriate and harmful depending on individual health factors, and determined the association between frailty and PIMs, adjusted for characteristics associated with PIMs.

METHODS

This prospective longitudinal study included 9355 participants aged 77-82 years at baseline (2003). Frailty was measured using the FRAIL (fatigue, resistance, ambulation, illness and loss of weight) scale. Generalised estimating equations using log-binomial regressions determined the association between frailty and risk of using PIMs.

RESULTS

Among participants who were frail and non-frail at baseline, the majority used ≥ 3 PIMs (74.2% and 58.5%, respectively). At 2017, the proportion using ≥ 3 PIMs remained constant in the frail group (72.0%) but increased in the non-frail group (66.0%). Commonly prescribed medications that may be potentially inappropriate in both groups included benzodiazepines, proton-pump inhibitors and non-steroidal anti-inflammatory drugs, and risperidone was an additional contributor in the non-frail group. When adjusted for other characteristics, frail women had a 2% higher risk of using PIMs (RR 1.02; 95% CI 1.01, 1.03).

CONCLUSION

Given that the majority of frail women were using medications that may have been potentially inappropriate, it is important to consider both frailty and PIMs as indicators of health outcomes, and to review the need for PIMs for women aged 77-96 years who are frail.

Home Medicines Review and frailty among community-dwelling older women

OBJECTIVES

Home Medicines Reviews (HMRs) can optimize medications for frail older adults. This study aimed to determine the use of HMRs according to frailty status and the association between frailty and use of HMRs.

METHODS

The study included 9139 female participants enrolled in the Australian Longitudinal Study on Women's Health from 2003 (aged 77-82 years) to 2017 (aged 91-96 years). Generalized estimating equations (GEEs) using log-binomial regressions were used to determine associations using repeated measures on individuals over time.

KEY FINDINGS

The majority of participants in the study remained non-frail and did not receive HMRs from 2003 [7116 (77.86%)] to 2017 [1240 (71.31%)]. The use of HMRs was low in both groups with 33 (1.68%; 95% CI, 1.16 to 2.36) frail and 64 (0.89%; 95% CI, 0.69 to 1.14) non-frail participants receiving HMRs in 2003; by 2017, 19 (4.19%; 95% CI, 2.54 to 6.46) frail and 45 (3.50%; 95% CI, 2.57 to 4.66) non-frail participants received HMRs. Frailty was not associated with receiving a HMR (RR 1.06; 95% CI, 0.95 to 1.20), although for every 1-year increase, participants were 10% more likely to receive a HMR (RR 1.10; 95% CI, 1.09 to 1.11). Participants with continuous polypharmacy, ≥4 chronic diseases, >4 general practitioner visits and Department of Veterans Affairs coverage were more likely to receive a HMR.

CONCLUSIONS

Despite the proven value of HMRs for frail older people, HMRs were not used for most frail and non-frail community-dwelling women in this study. Reasons for low use of the service should be explored, with interventions to raise awareness of the benefits of the service.

An early predictive model of frailty for older inpatients according to nutritional risk: protocol for a cohort study in China

BACKGROUND

Previous reports suggest that the attributes of frailty are multidimensional and include nutrition, cognition, mentality, and other aspects. We aim to develop an early warning model of frailty based on nutritional risk screening and apply the frailty early warning model in the clinic to screen high-risk patients and provide corresponding intervention target information.

METHODS

The proposed study includes two stages. In the first stage, we aim to develop a prediction model of frailty among older inpatients with nutritional risk. Study data were collected from a population-based aging cohort study in China. A prospective cohort study design will be used in the second stage of the study. We will recruit 266 older inpatients (age 65 years or older) with nutritional risk, and we will apply the frailty model in the clinic to explore the predictive ability of the model in participants, assess patients' health outcomes with implementation of the frailty model, and compare the model with existing frailty assessment tools. Patients' health outcomes will be measured at admission and at 30-day follow-up.

DISCUSSION

This project is the first to develop an early prediction model of frailty for older inpatients according to nutritional risk in a nationally representative sample of Chinese older inpatients of tertiary hospitals. The results will hopefully help to promote the development of more detailed frailty assessment tools according to nutritional risk, which may ultimately lead to reduced health care costs and improvement in independence and quality of life among geriatric patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR1800017682 , registered August 9, 2018; and ChiCTR2100044148 , registered March 11, 2021.

Common combinations of medications used among oldest-old women: a population-based study over 15 years

BACKGROUND

Older people use many medications, but combinations of medications used among the oldest old (≥ 80 years) are not commonly reported.

AIMS

This study aimed to determine common combinations of medications used among women aged 77-96 years and to describe characteristics associated with these combinations.

METHODS

A cohort study of older women enroled in the Australian Longitudinal Study on Women's Health over a 15-year period was used to determine combinations of medications using latent class analysis. Multinomial logistic regression was used to determine characteristics associated with these combinations.

RESULTS

The highest medication users during the study were for the cardiovascular (2003: 80.28%; 2017: 85.63%) and nervous (2003: 66.03%; 2017: 75.41%) systems. A 3-class latent model described medication use combinations: class 1: 'Cardiovascular & neurology anatomical group' (27.25%) included participants using medications of the cardiovascular and nervous systems in their later years; class 2: 'Multiple anatomical group' (16.49%) and class 3: 'Antiinfectives & multiple anatomical group' (56.27%). When compared to the reference class (class 1), the risk of participants being in class 3 was slightly higher than being in class 2 if they had > 4 general practitioner visits (RRR 2.37; 95% CI 2.08, 2.71), Department of Veterans Affairs' coverage (RRR 1.59; 95% CI 1.36, 1.86), ≥ 4 chronic diseases (RRR 3.16; 95% CI 2.56, 3.90) and were frail (RRR 1.47; 95% CI 1.27, 1.69).

CONCLUSION

Identification of combinations of medication use may provide opportunities to develop multimorbidity guidelines and target medication reviews, and may help reduce medication load for older individuals.

Results of High-Protein, High-Calorie Oral Nutritional Supplementation in Malnourished Older People in Nursing Homes: An Observational, Multicenter, Prospective, Pragmatic Study (PROT-e-GER)

OBJECTIVES

To assess if the impact of oral nutritional supplements (ONS) on nutritional and functional status in malnourished older persons living in nursing homes shown by clinical trials are also found outside a trial setting.

DESIGN

Observational, multicenter, prospective, pragmatic study.

SETTING AND PARTICIPANTS

This study was carried out in 38 nursing homes throughout Spain. Nursing home physicians recruited consecutive residents, older than 65 years, with a diagnosis of malnutrition, when a clinical decision to start ONS had been taken after unsuccessful initial management with dietary interventions.

INTERVENTION

The participants received daily 2 bottles of an energy-rich, high-protein commercial ONS for 3 months.

MEASURES

Primary outcomes were changes in nutritional status [body weight, body mass index (BMI), and Mini Nutritional Assessment-Short Form (MNA-SF)]; secondary outcomes were functional changes [Functional Ambulation Classification, Barthel index, handgrip strength, and Short Physical Performance Battery (SPPB)], as well as safety and adherence after 12 weeks of follow-up.

RESULTS

A total of 282 residents (median age 86 years, 67% women) were included, and 244 (86.5%) completed the follow-up. At baseline, 77.3% of the participants were malnourished (BMI 19.7 kg/m², interquartile range 18.3-21.8). After 12 weeks of follow-up, participants experienced significant increases in body weight (2.6 ± 3.1 kg, 5.2 ± 5.9%), BMI (1.0 ± 1.2 kg/m²) and MNA-SF (4.0 ± 2.5 points). There were also significant improvements in functional status measured by the Barthel index, handgrip strength, SPPB, and gait speed. Good adherence was registered in 94.6% of the participants. No relevant side effects were found.

CONCLUSIONS AND IMPLICATIONS

Improvements in nutritional and functional status can be found when using a high-protein, high-calorie ONS in older undernourished people living in nursing homes.

Sex differences in dietary consumption and its association with frailty among middle-aged and older Australians: a 10-year longitudinal survey

Background

Nutritional status has been considered as a key factor in preventing the development of the frailty syndrome. However, sex-specific dietary consumption transition over time and how it impacts of frailty status are unclear.

Method

We assessed 113,039 adults (aged 50 years and over) from the 45 and Up Study who had completed both baseline (2006–2009) and follow-up (2012–2015) surveys. Dietary consumption was assessed by a short food frequency questionnaire. Frailty was identified by the FRAIL scale. Multinomial regression models were used to examine the association between a long-term dietary consumption and frailty, stratified by sex.

Results

Of a total of 113,039 participants, females had a higher percentage of pre-frailty and frailty than males (pre-frailty: 35.5% for female and 30.1% for male; frailty: 4.86% for female and 3.56% for male). As age increased, males had significant decreases in overall dietary risk scores, while females had significant increases in overall dietary risk scores. Males and females with a long-term consumption of adequate fruits, high grains or had a variety of foods were related to a low risk of frailty. Females with a long-term consumption of adequate vegetables or high lean meats and poultry were related to a low risk of frailty. Females with an unhealthy diet at both surveys [Relative Risk Ratio (RRR) = 1.32, 95% CI: 1.18; 1.49], and those with unhealthy diet at either surveys (RRR = 1.28, 95% CI: 1.12; 1.47, RRR = 1.19, 95% CI: 1.04; 1.37) had a higher risk of frailty compared to those had a long-term healthy diet. No association were found between overall dietary risk and frailty for males.

Conclusion

Males and females changed their dietary consumption as they age. These changes affect its association with frailty, particularly for females. Sex-specific dietary advice in prevention of frailty needs to be further developed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02165-2.

Frailty, walking ability and self-rated health in predicting institutionalization: an 18-year follow-up study among Finnish community-dwelling older people

Background

In clinical practice, there is a need for an instrument to screen older people at risk of institutionalization.

Aims

To analyze the association of frailty, walking-ability and self-rated health (SRH) with institutionalization in Finnish community-dwelling older people.

Methods

In this prospective study with 10- and 18-year follow-ups, frailty was assessed using FRAIL Scale (FS) (n = 1087), Frailty Index (FI) (n = 1061) and PRISMA-7 (n = 1055). Walking ability was assessed as self-reported ability to walk 400 m (n = 1101). SRH was assessed by a question of general SRH (n = 1105). Cox regression model was used to analyze the association of the explanatory variables with institutionalization.

Results

The mean age of the participants was 73.0 (range 64.0‒97.0) years. Prevalence of institutionalization was 40.8%. In unadjusted models, frailty was associated with a higher risk of institutionalization by FS in 10-year follow-up, and FI in both follow-ups. Associations by FI persisted after age- and gender-adjustments in both follow-ups. By PRISMA-7, frailty predicted a higher risk of institutionalization in both follow-ups. In unadjusted models, inability to walk 400 m predicted a higher risk of institutionalization in both follow-ups and after adjustments in 10-year follow-up. Poor SRH predicted a higher risk of institutionalization in unadjusted models in both follow-ups and after adjustments in 10-year follow-up.

Discussion

Simple self-reported items of walking ability and SRH seemed to be comparable with frailty indexes in predicting institutionalization among community-dwelling older people in 10-year follow-up.

Conclusions

In clinical practice, self-reported walking ability and SRH could be used to screen those at risk.

Electronic supplementary material

The online version of this article (10.1007/s40520-020-01551-x) contains supplementary material, which is available to authorized users.

Vascular endothelial dysfunction may be an early predictor of physical frailty and sarcopenia: A meta-analysis of available data from observational studies

BACKGROUND

Physical frailty and sarcopenia (PF & S) are major public health problems in the older population and promising predictors of adverse cardiovascular outcomes. However, the underlying mechanisms linking physical frailty, sarcopenia and adverse cardiovascular outcomes are not well defined. We recently published a systematic review which highlighted early-stage vascular endothelial dysfunction (VED) as one of the potential underlying mechanisms of physical frailty and the role of inflammation in modulating this association.

OBJECTIVE AND METHOD

A meta-analysis was performed to estimate the pooled effect size of studies examining the relationship between VED and PF & S.

RESULTS

Out of 18 cross-sectional studies selected for the original review, 13 studies were excluded due to lack of available data for pooled analysis. The five remaining studies had a total of 6616 participants, of which the pooled sample size of the frail or sarcopenic cohort was 607 and robust or pre-frail or non-sarcopenic cohort was 6009. Mean age of the participants ranging from 64 to 80 years or over. In this analysis, high heterogeneity was observed among studies (99.35% of the variation between studies was due to heterogeneity). Parameters used to assess both PF & S and VED were very different across the studies.

CONCLUSION

The absence of a standardized and valid operational definition of frailty and sarcopenia is a principal limiting factors for frailty research and this is clearly reflected in our study findings. This limits the ability to interpret and define the effects of vascular endothelial dysfunction on these different parameters of frailty and sarcopenia. Similarly, assessment of vascular endothelial dysfunction was very heterogeneous with different parameters utilized across these studies.

Prevalence and association of continuous polypharmacy and frailty among older women: A longitudinal analysis over 15 years

OBJECTIVES

This study aimed to determine the prevalence of continuous polypharmacy and hyperpolypharmacy, determine medications that contribute to continuous polypharmacy, and examine the association between frailty and continuous polypharmacy.

STUDY DESIGN

A prospective study using data from the Australian Longitudinal Study on Women's Health. Women aged 77-82 years in 2003, and 91-96 years in 2017 were analysed, linking the Pharmaceutical Benefits Scheme data to participants' survey data.

MAIN OUTCOME MEASURES

The association between frailty and continuous polypharmacy was determined using generalised estimating equations for log binomial regressions, controlling for confounding variables. Descriptive statistics were used to determine the proportion of women with polypharmacy, and medications that contributed to polypharmacy.

RESULTS

The proportion of women with continuous polypharmacy increased over time as they aged. Among participants who were frail (n = 833) in 2017, 35.9 % had continuous polypharmacy and 1.32 % had hyperpolypharmacy. Among those who were non-frail (n = 1966), 28.2 % had continuous polypharmacy, and 1.42 % had hyperpolypharmacy. Analgesics (e.g. paracetamol) and cardiovascular medications (e.g. furosemide and statins) commonly contributed to continuous polypharmacy among frail and non-frail women. Accounting for time and other characteristics, frail women had an 8% increased risk of continuous polypharmacy (RR 1.08; 95 % CI 1.05, 1.11) compared to non-frail women.

CONCLUSIONS

Combined, polypharmacy and frailty are key clinical and public health challenges. Given that one-third of women had continuous polypharmacy, monitoring and review of medication use among older women are important, and particularly among women who are frail.

Assessment of the validity and acceptability of the online FRAIL scale in identifying frailty among older people in community settings

OBJECTIVES

To assess the validity and acceptability of the online FRAIL scale in identifying frailty in community settings.

METHODS

Frailty was assessed using the online version of the FRAIL scale (a simple frailty questionnaire). Validity of the scale was examined in a sample of 1882 persons aged 60 years or older (inlcuding a pilot sample of 65 persons for assessing the face validity) recruited from 24 elderly centres in Hong Kong. Convergent validity was estimated using correlation coefficients between scores on the FRAIL, SARC-F (a simple questionnaire for assessing sarcopenia) and AMIC (Abbreviated Memory Inventory for the Chinese). Predictive validity was examined by logistic regression using IADL (Instrumental Activities of Daily Living) limitations and hospitalization as outcomes. Acceptability of the scale was assessed from the perspective of a sub-sample of 205 older persons and 33 centre staff.

RESULTS

Following minor revisions, all participants were able to understand and answer the online FRAIL scale. The FRAIL scale correlated with SARC-F (r = 0.627, p < 0.001) and AMIC (r = 0.302, p < 0.001). Being pre-frail and frail were associated with incident IADL limitations (OR = 1.58, 95 %CI = 1.11-2.25 and OR = 3.01, 95 %CI = 1.87-4.84, respectively) and incident hospitalization (OR = 1.38, 95 %CI = 1.03-1.85 and OR = 2.79, 95 %CI = 1.89-4.12, respectively) at year 2, after controlling for age, sex, marital status, and educational level. 77.8 % of participants agreed that the scale would enable them to understand their health status. However, only 35.0 % accepted a digital approach for conducting health assessment or accessing assessment results. 90.9 % of centre staff agreed that the scale could be used to identify their members who are potential candidates for frailty intervention.

CONCLUSIONS

The online FRAIL scale is valid for use in community elderly centres in identifying frailty. Further effort is required to improve the acceptability of the online FRAIL scale among older persons.

Nutritional domains in frailty tools: Working towards an operational definition of nutritional frailty

Different methods have been proposed for the assessment of the nutritional status in frailty phenotypes. In the present narrative review article, we have summarized the number and specifications of nutritional items in existing frailty tools, in order to develop a possible means of assessment and operational definition of the nutritional frailty phenotype. In six different databases until December 2019, we searched for original articles regarding frailty tools (i.e., scales, indexes, scores, questionnaires, instruments, evaluations, screening, indicators), analyzing each tool regarding nutritional items. We identified 160 articles describing 71 frailty tools. Among the selected frailty tools, 54 were community-based (70 %), 17 hospital-based (22 %), 4 validated in long-term care institutions for older adults (LTCIOA) (5.1 %) and 2 validated in both community- and hospital-based settings, including LTCIOA (2.5 %). Fifty-two of these tools (73 %) included at least one nutritional item. Twenty-two (42 %) reported two or more nutritional items. The items were grouped in the following categories: A) anthropometric measurements, B) laboratory measurements, and C) other nutritional-related measurements. Anthropometric measurements stood out compared to all other items. Nutritional items are included in the majority of frailty tools, strengthening the concept that they may have a direct implication on an increased risk of adverse health-related outcomes in frail subjects. This supports the development of the concept of nutritional frailty as an independent frailty phenotype. Subsequent steps will be to assess the contribution of each nutritional item to a possible operational definition of nutritional frailty and define the items that may best identify this new frailty phenotype.

Frailty and mortality: an 18-year follow-up study among Finnish community-dwelling older people

BACKGROUND

There is a lack of agreement about applicable instrument to screen frailty in clinical settings.

AIMS

To analyze the association between frailty and mortality in Finnish community-dwelling older people.

METHODS

This was a prospective study with 10- and 18-year follow-ups. Frailty was assessed using FRAIL scale (FS) (n = 1152), Rockwood's frailty index (FI) (n = 1126), and PRISMA-7 (n = 1124). To analyze the association between frailty and mortality, Cox regression model was used.

RESULTS

Prevalence of frailty varied from 2 to 24% based on the index used. In unadjusted models, frailty was associated with higher mortality according to FS (hazard ratio 7.96 [95% confidence interval 5.10-12.41] in 10-year follow-up, and 6.32 [4.17-9.57] in 18-year follow-up) and FI (5.97 [4.13-8.64], and 3.95 [3.16-4.94], respectively) in both follow-ups. Also being pre-frail was associated with higher mortality according to both indexes in both follow-ups (FS 2.19 [1.78-2.69], and 1.69 [1.46-1.96]; FI 1.81[1.25-2.62], and 1.31 [1.07-1.61], respectively). Associations persisted even after adjustments. Also according to PRISMA-7, a binary index (robust or frail), frailty was associated with higher mortality in 10- (4.41 [3.55-5.34]) and 18-year follow-ups (3.78 [3.19-4.49]).

DISCUSSION

Frailty was associated with higher mortality risk according to all three frailty screening instrument used. Simple and fast frailty indexes, FS and PRISMA-7, seemed to be comparable with a multidimensional time-consuming FI in predicting mortality among community-dwelling Finnish older people.

CONCLUSIONS

FS and PRISMA-7 are applicable frailty screening instruments in clinical setting among community-dwelling Finnish older people.

Use of the FRAIL Questionnaire in Patients With End-Stage Kidney Disease

Background:

Frailty is a clinical phenotype of decreased physiologic reserve that is associated with increased morbidity and mortality. The most meaningful way to assess frailty in patients with end-stage kidney disease (ESKD) is unknown.

Objective:

To assess the prevalence of frailty in ESKD patients using the easy-to-administer FRAIL scale and, to determine its association with mortality, transplantation, and hospitalization.

Design:

A cohort study was used.

Setting:

The Ottawa Hospital, Ottawa, Ontario, Canada, was the setting of this study.

Patients:

All eligible adult ESKD patients treated with dialysis from August to November 2017 at The Ottawa Hospital were invited to participate.

Measurements:

The FRAIL scale.

Methods:

Eligible patients completed an exercise survey with FRAIL questions embedded within the instrument. Number of comorbid illnesses was determined from the electronic medical record and weight loss was calculated from target weight in the patients’ dialysis prescription. Mortality, transplant status, and hospitalizations were ascertained from the electronic medical record 18 months later; differences by frailty status were evaluated using descriptive statistics. Kaplan-Meier and Cox regression models were used to examine the association between frailty and transplant.

Results:

Of 476 ESKD patients screened, 261 participated; 101 receiving peritoneal dialysis, 135 intermittent hemodialysis, and 25 home hemodialysis. Thirty-nine, 145, and 77 were frail, pre-frail, and not frail, respectively. Employment status, ethnicity, and comorbid illnesses differed significantly by frailty status, but mortality did not. In univariate analysis, frail patients were less likely to be listed for (P = .05) and to receive a kidney transplant (P = .02). However, after adjusting for age and modality, frailty was not statistically associated with a decreased likelihood of transplant (Hazard Ratio: 0.15; confidence interval [CI], 0.02-1.15; P = .068). The results were similar when accounting for the competing risk of death (P = .060). Frail patients were more likely to be hospitalized (P = .01) and spend more time in the hospital (P = .04).

Limitations:

Single-center design with a relatively short follow-up and small sample size limiting the number of variables that could be assessed in analysis. We also excluded patients who were unable to communicate in English or French and those patients with physical limitations such as amputations, potentially affecting generalizability.

Conclusions:

Frail ESKD patients as identified by the FRAIL scale are less likely to receive a renal transplant; this association diminished statistically after adjusting for age and modality and when accounting for the competing risk of death. Frail patients were at increased risk of hospitalization. Further study with larger patient numbers and longer follow-up is needed to determine the usefulness of the FRAIL scale in predicting adverse outcomes.

Trial registration:

Not required as this was an observational study.

FRAIL scale: Predictive validity and diagnostic test accuracy

OBJECTIVE

To examine the predictive validity of the FRAIL scale for mortality, and diagnostic test accuracy (DTA) against the frailty phenotype (FP).

MEASUREMENT

Frailty was measured in 846 community-dwelling adults (mean age 74.3 [SD 6.3] years, 54.8% female) using a modified FRAIL scale and modified FP. Mortality was matched to death records.

RESULTS

The FRAIL scale demonstrated significant predictive validity for mortality up to 10 years (Frail adjHR: 2.60, P < .001). DTA findings were acceptable for specificity (86.8%) and Youden index (0.50), but not sensitivity (63.6%), or area under the receiver operator curve (auROC) (0.75). DTA estimates were more acceptable when a cut-point of ≥2 characteristics was used rather than ≥3 in the primary DTA analysis.

CONCLUSION

The FRAIL scale is a valid predictor of mortality. DTA estimates depend on FRAIL scale cut-point used. This instrument is a potentially useful frailty screening tool.

Exploring psychosocial factors associated with frailty incidence among patients undergoing maintenance hemodialysis

AIM AND OBJECTIVE

We investigated the correlation between the frailty status of maintenance haemodialysis (MHD) patients and psychosocial factors.

BACKGROUND

Varying degrees of frailty have been reported in MHD patients, which affect their quality of life.

DESIGN

We adopted a cross-sectional design in this study.

METHODS

Clinical data of 187 patients at our centre were collected from December 2017-June 2018 using a cross-sectional survey. Psychosocial factors were measured using the Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale, 10-item Connor-Davidson Resilience Scale (CD-RISC), Chronic Disease Self-Efficacy Scales and Perceived Social Support Scale. Frailty status was estimated using the fatigue, resistance, ambulation, illnesses and loss of weight (FRAIL) scale. Spearman's correlation and multiple logistic regression analysis were conducted to identify the risk factors for frailty. This study complied with the STROBE checklist.

RESULTS

Of 187 patients, 11 cases (5.9%) of frailty were identified. Patient's age, comorbidities, parathyroid hormone level, sleep quality and depression were positively correlated with frailty (p < .05), while psychological resilience and social support were negatively correlated with frailty (p < .05). Logistic regression analysis revealed four risk factors for frailty among MHD patients, including age (p = .004), comorbidities (p = .023), depression (p = .023) and sleep disorders (p = .029). Conversely, protective factors included high psychological resilience (p = .019) and social support (p = .039).

CONCLUSION

Among MHD patients, the risk factors for frailty included age, comorbidity, depression and sleep disturbance, whereas the protective factors included psychological resilience and social support.

RELEVANCE TO CLINICAL PRACTICE

Frailty is not only common among older patients, but also among people of all age groups suffering from chronic diseases. Therefore, it is important to consider the health status of MHD patients and adopt targeted nursing strategies to alleviate symptoms of frailty and improve physical condition by the following ways: postpone the progress of comorbidities, improve sleep quality, control the symptoms of depression, foster psychological resilience and facilitate support from social and family.

Study protocol of a randomised controlled trial to examine the impact of a complex intervention in pre-frail older adults

BACKGROUND

Frailty is a multidimensional geriatric syndrome associated with functional loss. The Senior Chef (SC, nutrition) and SAYGO (strength and balance exercise) programmes are well accepted among older adults but the impact of each, or a combination of both, on the frailty syndrome in pre-frail older adults is unknown.

AIMS

To determine the effectiveness and cost-effectiveness of a complex intervention consisting of the SC and/or SAYGO programmes to prevent progression of frailty in pre-frail older adults.

METHODS

A multi-centre randomised controlled assessor-blinded study. The four intervention groups are SC, an 8-week nutrition education and cooking class; SAYGO, a 10-week strength and balance exercise class; SC plus SAYGO, and a social group (Control). Community-dwelling adults aged 75+ (60 + Māori and Pasifika) in New Zealand are recruited through health providers. Participants are not terminally ill or with advanced dementia, and have a score of 1 or 2 on the FRAIL questionnaire. Baseline assessments are completed using standardised questionnaires prior to randomisation. Four follow-up assessments are completed: immediately after intervention, 6, 12 and 24 months post-intervention. The primary outcome is frailty score, secondary outcomes are falls, physical function, quality of life, food intake, physical activity, and sustainability of the strategy. Study outcomes will be analysed using intention-to-treat approach. Cost analyses will be completed to determine if interventions are cost effective relative to the control group.

DISCUSSION

This trial is designed to be a real world rigorous assessment of whether the two intervention strategies can prevent progression of frailty in older people. If successful, this will generate valuable information about effectiveness of this nutrition and exercise strategy, and provide insights for their implementation.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry number-ACTRN12614000827639.

Frailty in cardiovascular disease: Screening tools

Cardiovascular disease (CVD) is the leading cause of death in developed countries and disproportionately affects older adults. Frailty is a complex clinical syndrome with multiple causes and contributing factors in which there is increased vulnerability when exposed to a minor stressor and increased risk for adverse outcomes, such as disability, hospitalization and mortality. Frailty is an important prognostic factor in patients with CVD, and so identifying this feature when assessing these patients may help to individually tailor cardiovascular treatment. The first step is to identify frailty. Several tools have been validated as screening methods for frailty. However, they diverge with regard to complexity, nature, feasibility and the outcome they can predict. The aim of this review is to describe the available screening tools for frailty and to examine their usefulness in patients with CVD.

Treatable traits in acute exacerbations of chronic airway diseases

Acute exacerbations of chronic airway disease are common occurrences that cause a major burden of illness. Acute exacerbations are associated with impaired health status, increased lung function decline, hospitalization and increased risk of death. Exacerbation avoidance is a major priority. Despite this goal, exacerbations continue to occur and the need for effective models of care that optimize patient outcomes are urgently needed. 'Treatable Traits' is an approach to personalized medicine that has been proposed for the management of airway diseases. The treatable traits approach allows for the recognition of clinically important, identifiable and treatable disease characteristics, followed by targeted and individualized treatment interventions to address each trait. We review the literature relating to treatable traits in airway diseases; in particular, those traits that can predict exacerbations and approaches to management that aim to prevent exacerbations by using a treatable traits model of care. We propose this approach as a potentially useful model of care to both prevent and manage acute exacerbations.

Influence of frailty on anticoagulant prescription and clinical outcomes after 1-year follow-up in hospitalised older patients with atrial fibrillation

Frailty is an important prognostic factor in older adults with cardiovascular diseases. We aim to describe the characteristics of elderly hospitalised frail patients with non-valvular atrial fibrillation (NVAF) and to assess the influence of frailty, along with other functional and health status variables on anticoagulation prescription, 1-year all-cause mortality, and the incidence of ischemic and bleeding complications. An observational, prospective multicentre study was carried out on patients with NVAF over the age of 75, who were admitted to the Internal Medicine departments in Spain. A total of 615 patients were evaluated (mean age 85.23 ± 5.16 years, 54.3% females, 48.3% frail). Frail patients had higher CHA2DS2-VASc and HAS-BLED scores, more comorbidities and worse functional status and cognitive impairment compared to non-frail. During hospitalisation, 58 (9.4%) patients died (12.5% frail, 6.6% non-frail, p = 0.01). Among the participants discharged, 69.8% received anticoagulants, 13% anti-platelets only and 16.9% no anti-thrombotics, with no difference by frailty status. Frailty is not a predictor of anticoagulant prescription at discharge (OR 0.93, 95% CI 0.55-1.57), while functional dependency remains significantly associated (OR for severe dependency 0.44, 95% CI 0.23-0.82). After the 1-year follow-up, frail patients have a higher risk of death (HR 1.99, 95% CI 1.43-2.76). Among patients taking anticoagulants, the incidence of stroke and major bleeding is similar between frailty groups. In our study, frailty is related to worse global health status. It has no impact on antithrombotic prescription, nor is a predictor of AF complications, even though frail subjects have a higher mortality during hospitalisation and after 1-year follow-up.

Combined Influence of Depression and Physical Frailty on Cognitive Impairment in Patients with Heart Failure

Cognitive impairment is a prevalent condition and important barrier to self-care behaviors in patients with heart failure (HF). HF patients with depression or physical frailty are more likely to have reduced cognitive function. However, it remains unclear if combined depression and physical frailty increased the risk of cognitive impairments among HF populations. This study aimed to identify the influence of combined depression and physical frailty on cognitive impairments in HF. This cross-sectional study was included 289 patients with HF in outpatient cardiology clinics at a tertiary care university hospital in Cheonan, South Korea. We obtained patients’ characteristics including depression, physical frailty, and cognitive function with Korean validated tools using a face-to-face interview. The prevalence rate of cognitive impairment was approximately 27.3% in HF outpatients. We found that the combined influence of depression and physical frailty increased the risk of cognitive impairments in both unadjusted (odds ratio (OR) 4.360; 95% confidence interval (CI) (2.113, 8.994)) and adjusted models (OR 3.545; 95% CI (1.448, 8.681)). Our findings highlight that healthcare professionals need to be more aware of the vulnerable population who suffer from both depression and physical frailty at the same time. Future prospective studies should examine the causal relationships among depression, physical frailty and cognitive impairment during the HF illness trajectories.

Quick and Simple FRAIL Scale Predicts Incident Activities of Daily Living (ADL) and Instrumental ADL (IADL) Disabilities: A Systematic Review and Meta-analysis

OBJECTIVES

To quantitatively examine frailty defined by FRAIL scale as a predictor of incident disability risks by conducting a systematic review and meta-analysis.

DESIGN

Systematic review and meta-analysis.

SETTING

A systematic review was conducted using 4 electronic databases (Embase, MEDLINE, CINAHL, and PsycINFO) in April 2018 for prospective cohort studies of middle-aged or older people examining associations between frailty and incident disability. Reference lists of the included studies were hand-searched for additional studies. Authors of potentially eligible studies were contacted for additional data if necessary. Methodological quality was assessed by the Newcastle-Ottawa scale.

PARTICIPANTS

Community-dwelling middle-aged and older people.

MEASUREMENTS

Incident risks of activities of daily living (ADL) or instrumental activities of daily living (IADL) disability according the FRAIL scale-defined frailty.

RESULTS

Seven studies provided odds ratios of incident disability risks according to frailty and were included in the meta-analysis. A random effects meta-analysis showed that frailty and prefrailty were significant predictors of ADL [pooled odds ratio (OR) = 9.82, 95% confidence interval (CI) = 4.71-20.46, P < .001 for frailty (FRAIL scale = 3-5) and pooled OR = 2.08, 95% CI = 1.77-2.45, P < .001 for prefrailty (FRAIL scale = 1-2) compared with robustness (FRAIL scale = 0); pooled OR = 4.44, 95% CI = 3.26-6.04, P < .001 for frailty compared with nonfrailty (FRAIL scale = 0-2)] and IADL (pooled OR = 2.50, 95% CI = 1.67-3.73, P < .001, for frailty and pooled OR = 1.74, 95% CI = 1.10-2.77, P = .02, for prefrailty compared with robustness). There was no evidence of publication bias.

CONCLUSIONS/IMPLICATIONS

The current study demonstrated that frailty status defined by the FRAIL scale was a significant predictor of disability among community-dwelling middle-aged and older individuals. In light of feasibility of the FRAIL scale, especially in a clinical setting, it may be a promising tool to facilitate the translation of frailty research into clinical practice.

The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty

OBJECTIVE

To develop Clinical Practice Guidelines for the screening, assessment and management of the geriatric condition of frailty.

METHODS

An adapted Grading of Recommendations, Assessment, Development, and Evaluation approach was used to develop the guidelines. This process involved detailed evaluation of the current scientific evidence paired with expert panel interpretation. Three categories of Clinical Practice Guidelines recommendations were developed: strong, conditional, and no recommendation.

RECOMMENDATIONS

Strong recommendations were (1) use a validated measurement tool to identify frailty; (2) prescribe physical activity with a resistance training component; and (3) address polypharmacy by reducing or deprescribing any inappropriate/superfluous medications. Conditional recommendations were (1) screen for, and address modifiable causes of fatigue; (2) for persons exhibiting unintentional weight loss, screen for reversible causes and consider food fortification and protein/caloric supplementation; and (3) prescribe vitamin D for individuals deficient in vitamin D. No recommendation was given regarding the provision of a patient support and education plan.

CONCLUSIONS

The recommendations provided herein are intended for use by healthcare providers in their management of older adults with frailty in the Asia Pacific region. It is proposed that regional guideline support committees be formed to help provide regular updates to these evidence-based guidelines.

Frailty in a racially and socioeconomically diverse sample of middle-aged Americans in Baltimore

Frailty is a risk factor for disability and mortality, and is more prevalent among African American (AA) elderly than whites. We examine frailty in middle-aged racially and economically diverse adults, and investigate how race, poverty and frailty are associated with mortality. Data were from 2541 participants in the Healthy Aging in Neighborhoods of Diversity across the Life Span study in Baltimore, Maryland; 35–64 years old at initial assessment (56% women; 58% AA). Frailty was assessed using a modified FRAIL scale of fatigue, resistance, ambulation, illness and weight loss, and compared with difficulties in physical functioning and daily activities. Frailty prevalence was calculated across race and age groups, and associations with survival were assessed by Cox Regression. 278 participants were frail (11%); 924 pre-frail (36%); 1339 not frail (53%). For those aged 45–54, a higher proportion of whites (13%) than AAs (8%) were frail; while the proportions were similar for those 55–64 (14%,16%). Frailty was associated with overall survival with an average follow-up of 6.6 years, independent of race, sex and poverty status (HR = 2.30; 95%CI 1.67–3.18). In this sample of economically and racially diverse older adults, the known association of frailty prevalence and age differed across race with whites having higher prevalence at younger ages. Frailty was associated with survival beyond the risk factors of race and poverty status in this middle-aged group. Early recognition of frailty at these younger ages may provide an effective method for preventing or delaying disabilities.

Frailty and Sarcopenia as Predictors of Adverse Health Outcomes in Persons With Diabetes Mellitus

OBJECTIVES

Diabetes mellitus is associated with premature aging, and chronic diabetes is associated with significant physical and cognitive complications. We aimed to examine frailty and sarcopenia rates and 6-month health outcomes in a clinic-based sample of patients with diabetes.

DESIGN

This study was an observational study. Participants were recruited from June 2014 to August 2014, and follow-up was conducted 6 months after day of screening.

SETTING

Participants were recruited at outpatient endocrinology, geriatric, and internal medicine clinics affiliated with Saint Louis University in St. Louis, Missouri.

PARTICIPANTS

Participants were persons with diabetes mellitus ages 50 to 90.

MEASUREMENTS

Frailty and sarcopenia were identified using the FRAIL and SARC-F screens, respectively. A chart review of the patient's health record was performed on day of screening and at follow-up. A 6-month phone questionnaire was performed to evaluate health outcomes. Logistic regressions were used to evaluate health outcomes.

RESULTS

A total of 198 persons with diabetes were recruited. Of the sample, 32.3% of sample was nonfrail, 38.9% was prefrail, and 28.8% was frail; 29.3% of the sample was identified to have sarcopenia. Prefrail [odds ratio (OR) 2.92, 95% confidence interval (CI) 1.15-7.42; P = .025] and frail (OR 4.70, 95% CI 1.67-13.19; P = .003) participants were more likely to be hospitalized overnight at 6-month follow-up. Frail (OR 3.57 95% CI 1.27-10.04; P = .016) participants were more likely to have a new activities of daily living (ADL) disability at follow-up; this association was not present for prefrail participants (OR 1.30, 95% CI .50-3.37; P = .59). Participants with sarcopenia were more likely to be hospitalized (OR 3.80, 95% CI 1.67-8.61; P = .001) and to have a new ADL disability (OR 4.24, 95% CI 1.76-10.18; P = .001) at 6-month follow-up.

CONCLUSIONS

Among clinic patients with diabetes mellitus ages 50-90 year old, frailty and sarcopenia prevalence is high, and both syndromes are predictors of being hospitalized overnight and new ADL disability after 6 months.