Cohort differences in the levels and trajectories of frailty among older people in England

Impact of caregiving on frailty in older spousal caregivers: A retrospective cohort study

Older spousal caregivers bear the dual burden of managing health changes and caring for their partners. This study aimed to investigate the association between spousal caregiving and frailty in older adults. A retrospective cohort study with a 4-year follow-up was conducted using seven waves of data from the Health and Retirement Study (2006-2018). The mean age of participants was 65.1 years. A significant correlation was found between spousal caregiving and frailty increase. Multilevel analysis demonstrated a significant difference in the changes in frailty index over 12 years between caregivers and non-caregivers. This study uncovered a significant association between spousal caregiving and frailty in older adults, suggesting that becoming a spousal caregiver is not only linked to higher levels of frailty but also accelerates its progression. Healthcare providers can tailor support services to assist caregivers in managing challenges and promoting healthy aging.

Frailty or frailties: exploring frailty index subdimensions in the English Longitudinal Study of Ageing

BACKGROUND

Frailty, a state of increased vulnerability to adverse health outcomes, has garnered significant attention in research and clinical practice. Existing constructs aggregate clinical features or health deficits into a single score. While simple and interpretable, this approach may overlook the complexity of frailty and not capture the full range of variation between individuals.

METHODS

Exploratory factor analysis was used to infer latent dimensions of a frailty index constructed using survey data from the English Longitudinal Study of Ageing, wave 9. The dataset included 58 self-reported health deficits in a representative sample of community-dwelling adults aged 65+ (N=4971). Deficits encompassed chronic disease, general health status, mobility, independence with activities of daily living, psychological well-being, memory and cognition. Multiple linear regression examined associations with CASP-19 quality of life scores.

RESULTS

Factor analysis revealed four frailty subdimensions. Based on the component deficits with the highest loading values, these factors were labelled 'mobility impairment and physical morbidity', 'difficulties in daily activities', 'mental health' and 'disorientation in time'. The four subdimensions were a better predictor of quality of life than frailty index scores.

CONCLUSIONS

Distinct subdimensions of frailty can be identified from standard index scores. A decomposed approach to understanding frailty has a potential to provide a more nuanced understanding of an individual's state of health across multiple deficits.

Secular trends in frailty among community-dwelling 75-95-year-old cohorts over three decades in Helsinki, Finland

BACKGROUND

Frailty Index (FI) reflects health, functioning and well-being of older people. It is valuable to compare how frailty has changed over time in ageing cohorts. This study aims to examine trends in frailty among 75-95-year-old men and women over three decades.

METHODS

The Helsinki Ageing Study started in 1989 and includes repeated cross-sectional postal surveys every 10 years examining community-dwelling cohorts of older people (75, 80, 85, 90 and 95 years). FI comprises the same 36 items in each cohort.

RESULTS

The mean FI was 0.22 (SD 0.12), 0.25 (SD 0.15), 0.26 (SD 0.15) and 0.23 (SD 0.15) in 1989, 1999, 2009 and 2019, respectively (P for linearity for crude values .11). Adjusted for age and sex, the four cohorts differed in their frailty the 2019 cohort having the lowest FI. This sex-adjusted difference was seen among 75-, 80-, 85- and 90-year-olds but not among 95-year-olds. FI decreased more among men than women (P for cohort <.001, P for sex <.01, P for interaction = .19).

CONCLUSIONS

The prevalence of frailty among community-dwelling individuals aged 75, 80, 85 and 90 years-but not among those aged 95 years-has significantly decreased over the last decades. This positive trend may have important implications for health policies in societies with increasing longevity.

Skeletal muscle dysfunction with advancing age

As a result of advances in medical treatments and associated policy over the last century, life expectancy has risen substantially and continues to increase globally. However, the disconnect between lifespan and 'health span' (the length of time spent in a healthy, disease-free state) has also increased, with skeletal muscle being a substantial contributor to this. Biological ageing is accompanied by declines in both skeletal muscle mass and function, termed sarcopenia. The mechanisms underpinning sarcopenia are multifactorial and are known to include marked alterations in muscle protein turnover and adaptations to the neural input to muscle. However, to date, the relative contribution of each factor remains largely unexplored. Specifically, muscle protein synthetic responses to key anabolic stimuli are blunted with advancing age, whilst alterations to neural components, spanning from the motor cortex and motoneuron excitability to the neuromuscular junction, may explain the greater magnitude of function losses when compared with mass. The consequences of these losses can be devastating for individuals, their support networks, and healthcare services; with clear detrimental impacts on both clinical (e.g., mortality, frailty, and post-treatment complications) and societal (e.g., independence maintenance) outcomes. Whether declines in muscle quantity and quality are an inevitable component of ageing remains to be completely understood. Nevertheless, strategies to mitigate these declines are of vital importance to improve the health span of older adults. This review aims to provide an overview of the declines in skeletal muscle mass and function with advancing age, describes the wide-ranging implications of these declines, and finally suggests strategies to mitigate them, including the merits of emerging pharmaceutical agents.

Longitudinal trajectories of frailty are associated with short-term mortality in older people: a joint latent class models analysis using 2 UK primary care databases

OBJECTIVES

Frailty is a dynamic health state that changes over time. Our hypothesis was that there are identifiable subgroups of the older population that have specific patterns of deterioration. The objective of this study was to evaluate the application of joint latent class model in identifying trajectories of frailty progression over time and their group-specific risk of death in older people.

STUDY DESIGN AND SETTING

The primary care records of UK patients, aged over 65 as of January 1, 2010, included in the Clinical Practice Research Datalink: GOLD and AURUM databases, were analyzed and linked to mortality data. The electronic frailty index (eFI) scores were calculated at baseline and annually in subsequent years (2010-2013). Joint latent class model was used to divide the population into clusters with different trajectories and associated mortality hazard ratios. The model was built in GOLD and validated in AURUM.

RESULTS

Five trajectory clusters were identified and characterized based on baseline and speed of progression: low-slow, low-moderate, low-rapid, high-slow, and high-rapid. The high-rapid cluster had the highest average starting eFI score; 7.9, while the low-rapid cluster had the steepest rate of eFI progression; 1.7. Taking the low-slow cluster as reference, low-rapid and high-rapid had the highest hazard ratios: 3.73 (95% CI 3.71, 3.76) and 3.63 (3.57-3.69), respectively. Good validation was found in the AURUM population.

CONCLUSION

Our research found that there are vulnerable subgroups of the older population who are currently frail or have rapid frailty progression. Such groups may be targeted for greater healthcare monitoring.

Longitudinal Quantiles of Frailty Trajectories Considering Death: New Insights into Sex and Cohort Differences in the Reference Curves for Frailty Progression of Older European

BACKGROUND

Most previous studies of frailty trajectories in older adults focus on the average trajectory and ignore death. Longitudinal quantile analysis of frailty trajectories permits the definition of reference curves, and the application of mortal cohort inference provides more realistic estimates than models that ignore death.

METHODS

Using data from individuals aged 65 or older (n = 25 446) from the Survey of Health, Ageing, and Retirement in Europe (SHARE) from 2004 to 2020, we derived repeated values of the Frailty Index (FI) based on the accumulation of health deficits. We applied weighted Generalized Estimating Equations to estimate the quantiles of the FI trajectory, adjusting for sample attrition due to death, sex, education, and cohort.

RESULTS

The FI quantiles increased with age and progressed faster for those with the highest level of frailty (β^a0.9 = 0.0229, p < .001; β^a0.5 = 0.0067, p < .001; H0: βa0.5=βa0.9, p < .001). Education was consistently associated with a slower progression of the FI in all quantiles (β^ae0.1 = -0.0001, p < .001; β^ae0.5 =-0.0004, p < .001; β^ae0.9 = -0.0003, p < .001) but sex differences varied across the quantiles. Women with the highest level of frailty showed a slower progression of the FI than men when considering death. Finally, no cohort effects were observed for the FI progression.

CONCLUSIONS

Quantile FI trajectories varied by age, sex, education, and cohort. These differences could inform the practice of interventions aimed at older adults with the highest level of frailty.

Higher baseline resting metabolic rate is associated with 1-year frailty decline among older adults residing in an urban area

BACKGROUND

Dysregulated energy metabolism is one hypothesized mechanism underlying frailty. Resting energy expenditure, as reflected by resting metabolic rate (RMR), makes up the largest component of total energy expenditure. Prior work relating RMR to frailty has largely been done in cross section with mixed results. We investigated whether and how RMR related to 1-year frailty change while adjusting for body composition.

METHODS

N = 116 urban, predominantly African-American older adults were recruited between 2011 and 2019. One-year frailty phenotype (0-5) was regressed on baseline RMR, frailty phenotype, demographics and body composition (DEXA) in an ordinal logistic regression model. Multimorbidity (Charlson comorbidity scale, polypharmacy) and cognitive function (Montreal Cognitive Assessment) were separately added to the model to assess for change to the RMR-frailty relationship. The model was then stratified by baseline frailty status (non-frail, pre-frail) to explore differential RMR effects across frailty.

RESULTS

Higher baseline RMR was associated with worse 1-year frailty (odds ratio = 1.006 for each kcal/day, p = 0.001) independent of baseline frailty, demographics, and body composition. Lower fat-free mass (odds ratio = 0.88 per kg mass, p = 0.008) was independently associated with worse 1-year frailty scores. Neither multimorbidity nor cognitive function altered these relationships. The associations between worse 1-year frailty and higher baseline RMR (odds ratio = 1.009, p < 0.001) and lower baseline fat-free mass (odds ratio = 0.81, p = 0.006) were strongest among those who were pre-frail at baseline.

DISCUSSION

We are among the first to relate RMR to 1-year change in frailty scores. Those with higher baseline RMR and lower fat-free mass had worse 1-year frailty scores, but these relationships were strongest among adults who were pre-frail at baseline. These relationships were not explained by chronic disease or impaired cognition. These results provide new evidence suggesting higher resting energy expenditure is associated with accelerate frailty decline.

Acceptability of physical activity signposting for pre-frail older adults: a qualitative study to inform intervention development

Frailty is a medical condition common in older adults characterised by diminished strength and reduced physiologic function in which individuals are more vulnerable to multiple adverse health outcomes. Pre-frailty is an intermediate stage associated with some minor health outcomes. However, the main risk is progression toward moderate/severe frailty. Evidence shows physical activity interventions to be effective in slowing or modifying the progression of frailty. Researchers at the University of Manchester are developing a behaviour change intervention targeting pre-frail older adults, signposting them to group-based physical activity classes known to be effective for delaying/slowing frailty. This paper reports on the initial intervention development work with key stakeholders exploring the practicality of taking forward this intervention and identifying uncertainties to be explored in the feasibility stage. These included issues around physical activity messaging, the use of the term 'frail', identification/recruitment of pre-frail older adults, and the acceptability of behaviour change techniques. There was overwhelming support for a proactive approach to addressing pre-frailty issues. Given that a large proportion of older adults are estimated to be pre-frail, interventions aimed at this group have the potential to support healthy ageing, positively impacting on frailty outcomes and providing wider population health benefits.

Long-term trajectories of frailty phenotype in older cancer survivors: a nationally representative longitudinal cohort study

BACKGROUND

Frailty is a dynamic process associated with adverse health outcomes. However, little is known about the long-term trajectories of frailty in older cancer survivors.

OBJECTIVES

To describe the trajectories of frailty phenotype over time amongst older cancer survivors and examine the socio-demographic and health-related predictors of different trajectories.

DESIGN

Population-based longitudinal cohort study.

SETTING

Community-dwelling older adults in the United States.

SUBJECTS

1,763 older adults who were diagnosed with cancer from the National Health and Ageing Trends Study.

METHODS

Frailty was assessed by the Fried Frailty Phenotype. The group-based trajectory model was used to identify the trajectories of frailty. Multinomial logistic regression analyses were used to examine the socio-demographic and health-related predictors of different trajectories.

RESULTS

Three frailty trajectories were identified; 52.8% of older cancer survivors had a sustained low risk of frailty over time, 25.0% had a low frailty risk at baseline but the risk increased steadily, and 22.3% had a high frailty risk with a slight change in the observed period. Older cancer survivors were at a high-risk frailty trajectory if they were older, female, African American, had lower education status, had lower annual income, were underweight or obese, self-rated poorer health, had more chronic conditions and difficulties with activities of daily living (ADL), and had worse cognitive functions (P < 0.05).

CONCLUSIONS

Long-term frailty trajectories in older cancer survivors are heterogeneous. This study helps identify patients at high risk of sustained or deteriorating frailty and has the potential to inform targeted frailty management strategies addressing modifiable factors identified (e.g. body mass index, ADL).

Adults Older Than Age 55 Engage in Less Diverse Activities Than Those 18 Years Ago

OBJECTIVES

Life-span perspectives have long acknowledged that individual functioning is shaped by historical and sociocultural contexts. Secular increases favoring recent cohorts are widely documented. However, little is known about secular trends in day-to-day activities and whether historical changes have occurred in younger and older adults alike.

METHODS

We compared data from 2 independent cohort samples of the daily diary portion of the Midlife in the United States Study obtained 18 years apart (1995/1996 cohort: n = 1,499 vs 2013/2014 cohort: n = 782) and identified case-matched cohorts (n = 757 per cohort) based on age, gender, education, and race. An activity diversity score was calculated based on 7 common daily activities, using Shannon's entropy method. We additionally examined the roles of age and other sociodemographic and health characteristics in cohort differences in activity diversity.

RESULTS

Results revealed that the 2013/2014 cohort experienced lower daily activity diversity than the 1995/1996 cohort. Age was positively associated with activity diversity in the 1995/1996 cohort, whereas age was negatively associated with activity diversity in the 2013/2014 cohort. These associations were significant for those who were older than age 55. Cohorts also differed in the types of most dominant activities and average time spent on those activities.

DISCUSSION

Findings show changes in the lifestyles and daily activities of U.S. adults across 2 decades. Contrasting to the common belief that today's adults may be healthier and more active, they seem engaging in less diverse daily activities, which can be a risk for future health outcomes.

Cohort Trajectories by Age and Gender for Informal Caregiving in Europe Adjusted for Sociodemographic Changes, 2004 and 2015

OBJECTIVES

We present a dynamic view of gender patterns in informal caregiving across Europe in a context of sociodemographic transformations. We aim to answer the following research questions: (a) has the gender gap in informal caregiving changed; (b) if so, is this due to changes among women and/or men; and (c) has the gender care gap changed differently across care regimes?

METHODS

Multilevel growth curve models are applied to gendered trajectories of informal caregiving of a panel sample of 50+ Europeans, grouped into 5-year cohorts and followed across 5 waves of the Survey of Health, Ageing and Retirement in Europe survey, stratified by sex and adjusted for several covariates.

RESULTS

For men in cohorts born more recently, there is a decrease in the prevalence of informal care outside the household, whereas cohort trajectories for women are mostly stable. Prevalence of care inside the household has increased for later-born cohorts for all without discernible changes to the gender care gap. Gender care gaps overall widened among later-born cohorts in the Continental cluster, whereas they remained constant in Southern Europe, and narrowed in the Nordic cluster.

DISCUSSION

We discuss the cohort effects found in the context of gender differences in employment and care around retirement age, as well as possible demographic explanations for these. The shift from care outside to inside the household, where it mostly consists of spousal care, may require different policies to support carers, whose age profile and possible care burden seem to be increasing.

Frailty transitions and prevalence in an ageing population: longitudinal analysis of primary care data from an open cohort of adults aged 50 and over in England, 2006-2017

INTRODUCTION

frailty is common in older adults and is associated with increased health and social care use. Longitudinal information is needed on population-level incidence, prevalence and frailty progression to plan services to meet future population needs.

METHODS

retrospective open cohort study using electronic health records of adults aged ≥50 from primary care in England, 2006-2017. Frailty was calculated annually using the electronic Frailty Index (eFI). Multistate models estimated transition rates between each frailty category, adjusting for sociodemographic characteristics. Prevalence overall for each eFI category (fit, mild, moderate and severe) was calculated.

RESULTS

the cohort included 2,171,497 patients and 15,514,734 person-years. Frailty prevalence increased from 26.5 (2006) to 38.9% (2017). The average age of frailty onset was 69; however, 10.8% of people aged 50-64 were already frail in 2006. Estimated transitions from fit to any level of frailty were 48/1,000 person-years aged 50-64, 130/1,000 person-years aged 65-74, 214/1,000 person-years aged 75-84 and 380/1,000 person-years aged ≥ 85. Transitions were independently associated with older age, higher deprivation, female sex, Asian ethnicity and urban dwelling. Mean time spent in each frailty category decreased with age, with the longest period spent in severe frailty at all ages.

CONCLUSIONS

frailty is prevalent in adults aged ≥50 and time spent in successive frailty states is longer as frailty progresses, resulting in extended healthcare burden. Larger population numbers and fewer transitions in adults aged 50-64 present an opportunity for earlier identification and intervention. A large increase in frailty over 12 years highlights the urgency of informed service planning in ageing populations.

Development of a UK core dataset for geriatric medicine research: a position statement and results from a Delphi consensus process

BACKGROUND

There is lack of standardisation in assessment tools used in geriatric medicine research, which makes pooling of data and cross-study comparisons difficult.

METHODS

We conducted a modified Delphi process to establish measures to be included within core and extended datasets for geriatric medicine research in the United Kingdom (UK). This included three complete questionnaire rounds, and one consensus meeting. Participants were selected from attendance at the NIHR Newcastle Biomedical Research Centre meeting, May 2019, and academic geriatric medicine e-mailing lists. Literature review was used to develop the initial questionnaire, with all responses then included in the second questionnaire. The third questionnaire used refined options from the second questionnaire with response ranking.

RESULTS

Ninety-eight responses were obtained across all questionnaire rounds (Initial: 19, Second: 21, Third: 58) from experienced and early career researchers in geriatric medicine. The initial questionnaire included 18 questions with short text responses, including one question for responders to suggest additional items. Twenty-six questions were included in the second questionnaire, with 108 within category options. The third questionnaire included three ranking, seven final agreement, and four binary option questions. Results were discussed at the consensus meeting. In our position statement, the final consensus dataset includes six core domains: demographics (age, gender, ethnicity, socioeconomic status), specified morbidities, functional ability (Barthel and/or Nottingham Extended Activities of Daily Living), Clinical Frailty Scale (CFS), cognition, and patient-reported outcome measures (dependent on research question). We also propose how additional variables should be measured within an extended dataset.

CONCLUSIONS

Our core and extended datasets represent current consensus opinion of academic geriatric medicine clinicians across the UK. We consider the development and further use of these datasets will strengthen collaboration between researchers and academic institutions.

Genetic and Environmental Influences on Longitudinal Frailty Trajectories From Adulthood into Old Age

BACKGROUND

Frailty is a complex, dynamic geriatric condition, but limited evidence has shown how genes and environment may contribute to its longitudinal changes. We sought to investigate sources of individual differences in the longitudinal trajectories of frailty, considering potential selection bias when including a sample of oldest-old twins.

METHODS

Data were from 2 Swedish twin cohort studies: a younger cohort comprising 1 842 adults aged 29-96 years followed up to 15 waves, and an older cohort comprising 654 adults aged ≥79 years followed up to 5 waves. Frailty was measured using the frailty index (FI). Age-based latent growth curve models were used to examine longitudinal trajectories, and extended to a biometric analysis to decompose variability into genetic and environmental etiologies.

RESULTS

A bilinear model with an inflection point at age 75 best described the data, indicating a fourfold to fivefold faster FI increase after 75 years. Twins from the older cohort had significantly higher mean FI at baseline but slower rate of increase afterward. FI level at age 75 was moderately heritable in both men (42%) and women (55%). Genetic influences were relatively stable across age for men and increasing for women, although the most salient amplification in FI variability after age 75 was due to individual-specific environmental influences for both men and women; conclusions were largely consistent when excluding the older cohort.

CONCLUSION

Increased heterogeneity of frailty in late life is mainly attributable to environmental influences, highlighting the importance of targeting environmental risk factors to mitigate frailty in older adults.

How Neighborhood Structural and Individual Characteristics Affect Frailty Progression: Evidence from the China Health and Retirement Longitudinal Study

OBJECTIVES

(1) To characterize the average trajectories of frailty over time in Chinese community-dwelling older adults; (2) To assess the effects of neighborhood structural and individual characteristics on frailty progression.

DESIGN

A nationally representative prospective cohort study.

SETTING

Communities in 28 provinces, China.

PARTICIPANTS

6238 respondents aged 60 and above in 447 communities from four waves of the China Health and Retirement Longitudinal Study.

MEASUREMENTS

Frailty was measured using the 61-item Frailty Index (FI).

RESULTS

The trajectory of FI was nonlinear, with an average growth rate of 0.025 that significantly slows down at the rate of 0.002 per year. Older, male, and uninsured respondents showed faster rates of growth in FI over time than younger, female, and insured counterparts. Respondents living in neighborhoods with a higher percentage of the older population and rural villages showed slower rates of growth in FI over time.

CONCLUSION

Expanding health insurance coverage and keeping a high clustering of the elderly in neighborhoods may be the potential strategies for population-level frailty prevention and interventions.

Characteristics of frailty phenotype in Chinese nursing home population and significance of motor function indicators in frailty assessment

The objectives of this study were to analyze the distribution characteristics of frailty phenotypes in older adults of Chinese nursing homes, and to compare some motor function characteristics of older adults in nursing homes between frailty and non-frailty, to determine which motor function and frailty are related. This cross-sectional study included 177 older adults living in nursing homes. Frailty was diagnosed by Fried's phenotype, and motor function assessment characteristics (including muscle tone, ROM, and balance) were also evaluated. Chi-square and logistic regression analyses were performed. Frailty prevalence was 53% in nursing homes in big Chinese cities (average age 82.0 ± 6.1). Low levels of physical activity (90.4% in frail elder), decreased handgrip strength (98.9% in frail elder) and slowed walking speed (100% in frail elder) were the 3 main components of the frailty phenotype of frail adults in nursing homes in China. It is worth noting that 74.7% of the non-frail elders also had reduced handgrip strength. Further analysis showed that balance (P < .001), muscle tone (upper, P = .028, lower, P = .001) and the range of motion (P < .001) were associated with frailty in older adults. The frailty of the elders in Chinese nursing homes was characterized by the decline of motor function. And surprisingly, both frail and non-frail elders were found to have poor strength. Frail nursing home seniors also have body muscle tone, range of motion and balance problems. The elderly of China should focus on strength, stretch and balance training to improve motor function, especially strength training, which is important for prevention frailty.

Cohort-specific disability trajectories among older women and men in Europe 2004-2017

As the population of Europe grows older, one crucial issue is how the incidence and prevalence of disabilities are developing over time in the older population. In this study, we compare cohort-specific disability trajectories in old age across subsequent birth cohorts in Europe, during the period 2004-2017.We used data from seven waves of data from the Survey of Health, Ageing and Retirement in Europe (SHARE). Mixed effects logistic regression models were used to model trajectories of accumulation of ADL limitations for subsequent birth cohorts of older women and men in different European regions. The results showed that there were sex differences in ADL and IADL limitations in all regions for most cohorts. Women reported more limitations than men, particularly in Eastern and Southern rather than Northern and Western Europe. Among men in Eastern, Northern and Western Europe, later born cohorts reported more disabilities than did earlier born birth cohorts at the same ages. Similar patterns were observed for women in Northern and Western Europe. In contrast, the risk of disabilities was lower in later born cohorts than in earlier born birth cohorts among women in Eastern Europe. Overall, results from this study suggest that disability trajectories in different cohorts of men and women were by and large similar across Europe. The trajectories varied more depending on sex, age and region than depending on cohort.

Trends in Frailty Between 1990 and 2020 in Sweden Among 75-, 85-, and 95-Year-Old Women and Men: A Nationwide Study from Sweden

BACKGROUND

Aging is the primary risk factor for frailty, which is defined as an inability to respond to acute or chronic stressors. Individuals are living longer with greater multimorbidity, but there is a paucity of evidence examining frailty across birth cohorts and ages.

METHODS

We investigated frailty prevalence and its association with mortality at ages 75, 85, and 95 in the 1895-1945 birth cohorts in Sweden with data from population registries. Frailty was assessed with the Hospital Frailty Risk Score (HFRS).

RESULTS

We observed that frailty increased with increasing age and that it has become more common in more recent birth cohorts. At age 75, the percent frail in the Total Population Register increased from 1.1% to 4.6% from birth cohorts 1915-1945, corresponding to calendar years 1990-2020. At age 85, the percentage of frail increased from 3.5% to 11.5% from birth cohorts 1905-1935, and at age 95 from birth cohorts 1895-1925, from 4.7% to 18.7%. Our results show that the increase was primarily driven by an increase in the distribution of individuals with scores in the highest quartile of HFRS, while the bottom 3 quartiles remained relatively stable across birth cohorts. Women accounted for a greater distribution of the overall population and frail population, though these disparities decreased over time. Despite increasing levels of frailty, the relationship between frailty and mortality did not change over time, nor did it differ by sex.

CONCLUSION

Increased frailty with improved survival points to a chronic condition that could be intervened upon.

Relationships between self-reported dyspnea, health conditions and frailty among Brazilian community-dwelling older adults: a cross-sectional study

CONTEXT

Dyspnea is a symptom present in several chronic diseases commonly seen among older adults. Since individuals with dyspnea tend to stay at rest, with consequently reduced levels of physical activity, they are likely to be at greater risk of developing frailty, especially at older ages.

DESIGN AND SETTING

Cross-sectional study at community level, Brazil.

OBJECTIVE

To analyze the relationships between self-reported dyspnea, health conditions and frailty status in a sample of community-dwelling older adults.

METHOD

Secondary data from the follow-up of the Frailty in Brazilian Elderly (FIBRA) study, involving 415 community-dwelling older adults (mean age: 80.3 ± 4.68 years), were used. The variables analyzed were sociodemographic characteristics, reported dyspnea, clinical data and frailty phenotype. Associations between dyspnea and other variables (age, sex, education and body mass index) were verified through the crude (c) and adjusted (a) odds ratios.

RESULTS

The prevalence of dyspnea in the entire sample was 21.0%. Dyspnea was more present in individuals with pulmonary diseases, heart disease, cancer and depression. Older adults with multimorbidities (adjusted odds ratio, ORa = 2.91; 95% confidence interval, CI = 1.41-5.99) and polypharmacy (ORa = 2.02; 95% CI = 1.15-3.54) were more likely to have dyspnea. Those who reported dyspnea were 2.54 times more likely to be frail (ORa = 2.54; 95% CI = 1.08-5.97), and fatigue was their most prevalent phenotype component.

CONCLUSION

Dyspnea was associated with different diseases, multimorbidities, polypharmacy and frailty. Recognizing the factors associated with dyspnea may contribute to its early identification and prevention of its negative outcomes among older adults.

A multifactorial interdisciplinary intervention to prevent functional and mobility decline for more participation in (pre-)frail community-dwelling older adults (PromeTheus): study protocol for a multicenter randomized controlled trial

BACKGROUND

Age-related decline in physical capacity can lead to frailty, associated with an increased vulnerability to adverse health outcomes and greater healthcare utilization. In an aging population, effective strategies to prevent physical decline and frailty, and preserve independence are needed. Prevention programs for vulnerable community-dwelling older adults are, however, often not yet established and implemented in routine practice. Research on the feasibility, implementation, and (cost-)effectiveness of multifactorial, interdisciplinary intervention programs that take advantage of available services of healthcare providers is also limited. The main aim of this study is to evaluate the effectiveness of such an intervention program (PromeTheus) to prevent functional and mobility decline for more participation in community-dwelling (pre-)frail older adults.

METHODS

The study is designed as a three-center, randomized controlled trial with a 12-month intervention period. Four hundred community-dwelling (pre-)frail (Clinical Frailty Scale score 4-6) older adults (≥70 years) will be randomized in a 1:1 ratio to the intervention group (IG) or the control group (CG). The IG will receive the PromeTheus program consisting of obligatory home-based physical exercises (Weight-bearing Exercise for Better Balance) accompanied by physiotherapists and facultative counseling services (person-environment-fit, coping with everyday life, nutrition, group-based activities) delivered via existing healthcare structures (e.g., social workers, nutritionists). The CG will receive usual care and a one-time counseling session on recommendations for physical activity and nutrition. Primary outcomes assessed at months 6 and 12 are the function component of the Late-Life Function and Disability Instrument and the University of Alabama at Birmingham Life-Space Assessment. Secondary outcomes are disability, physical capacity and activity, frailty, nutritional status, falls, fear of falling, health status, and psychosocial components. Process and economic evaluations are also conducted. Primary statistical analyses will be based on the intention-to-treat principle.

DISCUSSION

Compared to usual care, the PromeTheus program is expected to result in higher function and mobility, greater independence and lower need for care, and more participation. As the PromeTheus program draws on existing German healthcare structures, its large-scale translation and delivery will be feasible, if evidence of (cost-)effectiveness and successful implementation can be demonstrated.

TRIAL REGISTRATION

German Clinical Trials Register, . Registered on March 11, 2021.

Associations between frailty trajectories and frailty status and adverse outcomes in community-dwelling older adults

BACKGROUND

The association between frailty and adverse outcomes has been clearly defined. Frailty is associated with age, but different frailty evolution patterns might determine the incidence of adverse outcomes at older ages. So far, few observational studies have examined how distinct frailty trajectories could be associated with differences in the risk of adverse events and assessing whether frailty trajectories could define risk of death, hospitalization, worsening, and incident disability better than one-off assessment. Our hypothesis is that prospective increases in frailty levels are associated with higher risk of adverse events compared with subjects that prospectively decreased frailty levels.

METHODS

Participants' data were taken from the Toledo Study of Healthy Ageing. Frailty was evaluated using the Frailty Trait Scale 5 (FTS5), being 0 the lower (the most robust) and 50 the highest (the frailest) score. FTS5 scores at baseline and follow-up (median 5.04 years) were used to construct frailty trajectories according to group-based trajectory modelling (GBTM). Multivariate Cox proportional hazard and logistic regression models were used to explore associations between frailty status and trajectory membership and the adverse outcomes. Deaths were ascertained through the Spanish National Death Index. Disability was evaluated through the Katz Index. Hospitalization was defined as first admission to Toledo Hospital.

RESULTS

Nine hundred and seventy-five older adults (mean age 73.14 ± 4.69; 43.38% men) were included. GBTM identified five FTS5 trajectories: worsening from non-frailty (WNF), improving to non-frailty (INF), developing frailty (DF), remaining frail (RF), and increasing frailty (IF). Subjects belonging to trajectories of increasing frailty scores or showing consistently higher frailty levels presented with an increased risk of mortality {DF [hazard ratio (HR), 95% confidence interval (CI)] = 2.01 [1.21-3.32]; RF = 1.92 [1.18-3.12]; IF = 2.67 [1.48-4.81]}, incident [DF (HR, 95% CI) = 2.06 (1.11-3.82); RF = 2.29 (1.30-4.03); IF = 3.55 (1.37-9.24)], and worsening disability [DF (HR, 95% CI) = 2.11 (1.19-3.76); RF = 2.14 (1.26-3.64); IF = 2.21 (1.06-4.62)], compared with subjects prospectively showing decreases in frailty levels or maintaining low FTS5 scores. A secondary result was a significant dose-response relationship between baseline FTS5 score and adverse events.

CONCLUSIONS

Belonging to trajectories of prospectively increasing/consistently high frailty scores over time are associated with an increased risk of adverse outcomes compared with maintaining low or reducing frailty scores. Our results support the dynamic nature of frailty and the potential benefit of interventions aimed at reducing its levels on relevant and burdensome adverse outcomes.

Trajectories of Frailty With Aging: Coordinated Analysis of Five Longitudinal Studies

BACKGROUND AND OBJECTIVES

There is an urgent need to better understand frailty and its predisposing factors. Although numerous cross-sectional studies have identified various risk and protective factors of frailty, there is a limited understanding of longitudinal frailty progression. Furthermore, discrepancies in the methodologies of these studies hamper comparability of results. Here, we use a coordinated analytical approach in 5 independent cohorts to evaluate longitudinal trajectories of frailty and the effect of 3 previously identified critical risk factors: sex, age, and education.

RESEARCH DESIGN AND METHODS

We derived a frailty index (FI) for 5 cohorts based on the accumulation of deficits approach. Four linear and quadratic growth curve models were fit in each cohort independently. Models were adjusted for sex/gender, age, years of education, and a sex/gender-by-age interaction term.

RESULTS

Models describing linear progression of frailty best fit the data. Annual increases in FI ranged from 0.002 in the Invecchiare in Chianti cohort to 0.009 in the Longitudinal Aging Study Amsterdam (LASA). Women had consistently higher levels of frailty than men in all cohorts, ranging from an increase in the mean FI in women from 0.014 in the Health and Retirement Study cohort to 0.046 in the LASA cohort. However, the associations between sex/gender and rate of frailty progression were mixed. There was significant heterogeneity in within-person trajectories of frailty about the mean curves.

DISCUSSION AND IMPLICATIONS

Our findings of linear longitudinal increases in frailty highlight important avenues for future research. Specifically, we encourage further research to identify potential effect modifiers or groups that would benefit from targeted or personalized interventions.

Heterogeneity of Frailty Trajectories and Associated Factors in the Lothian Birth Cohort 1936

INTRODUCTION

Recent research suggests that the experience of frailty progression may be heterogeneous, with latent subpopulations of older adults following distinct trajectories of frailty. We aimed to investigate this notion and determine whether certain factors are associated with the membership of these subpopulations.

METHODS

Data from 5 data waves collected over 12 years in participants of the Lothian Birth Cohort 1936, aged 70 at baseline, were used to derive the frailty index (FI) (NW1 = 1,091, NW5 = 431). These were used in latent class mixed modelling to estimate subpopulations of frailty trajectories.

RESULTS

A quadratic latent class mixed model found 3 distinct groupings, which followed a low (61%, n = 632), medium (36%, n = 368), or high (3%, n = 28) FI trajectory. Each grouping had different intercepts and slopes, with the high grouping following the steepest trajectory indicating a rapid increase in frailty. Findings showed that in general, those in the low grouping were younger, had higher education, higher age 11 cognitive ability, and were from a higher social class than those in the medium and high groupings.

DISCUSSION/CONCLUSION

Our findings demonstrate heterogeneity in frailty trajectories over 12 years in individuals aged 70 years at baseline. Membership of higher frailty trajectory groupings was associated with lower social class, less education, and lower childhood cognitive ability, indicating the potential for future interventions to target individuals who are at the greatest risk of belonging to the high frailty trajectory. Future research is required to continue this line of inquiry by exploring other risk and protective factors, and importantly, to assess whether it is possible to realign an individual's membership to a less detrimental grouping of frailty trajectory.

Longitudinal changes of frailty in 8 years: comparisons between physical frailty and frailty index

Background

Few studies have made longitudinal comparisons between frailty phenotype (FP) and frailty index (FI) changes. We aimed to investigate frailty status changes defined by FP and FI concurrently, and to compare the associated factors and incident disability among different combination of FI and FP trajectory groups.

Methods

Data on respondents aged over 50 who completed the 1999, 2003 and 2007 Taiwan Longitudinal Study on Aging (TLSA) surveys (n = 2807) were excerpted. Changes of FI, FP and major time-dependent variables were constructed by group-based trajectory modeling. Logistic regression was used to investigate the associated factors and relationships with incident disability among different frailty trajectories.

Results

We identified four FP trajectories – stably robust, worsened frailty, improved frailty, and stably frail and three FI trajectories – stable FI, moderate increase FI and rapid increase FI. Lower self-rated health, mobility impairment, and depressed mood were associated with unfavorable FP and FI changes (all p < 0.001). Regardless of FP trajectory groups, the moderate and rapid increase FI group had significantly more comorbidities than the stable FI group, and more visual, hearing, oral intake impairment, more difficulty in meeting living expenses, and poorer cognitive function in ≥65-year-olds (all p < 0.05). In addition, the worsened frailty, improved frailty, and stably frail groups had ORs for incident disability of 10.5, 3.0, and 13.4, respectively, compared with the stably robust group (all p < 0.01); the moderate and rapid increase FI groups had 8.4-fold and 77.5-fold higher risk than the stable FI group (both p < 0.001). When combining FI and FP trajectories, risk increased with FI trajectory steepness, independent of FP change (all p < 0.01 in rapid increase FI vs stable FI).

Conclusions

Four FP trajectories (stably robust, worsened frailty, improved frailty, and stably frail) and three FI trajectories (stable FI, moderate increase FI and rapid increase FI) were identified. Lower self-rated health, mobility impairment, and depressed mood were associated with both unfavorable FP and FI trajectories. Nevertheless, even for individuals in stably robust or improved frailty FP groups, moderate or rapid increase in FI, either due to comorbidities, sensory impairment, cognitive deficits, or financial challenges, may still increase the risk of incident disability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02665-1.

2015-2016 Normative Data for the 3-m Usual Walk, Five Repeated Chair Stands, and Static Balance Components of the SPPB Among U.S. Older Adults Across Two Nationally Representative Data Sets: NSHAP and NHATS

OBJECTIVES

Our primary objective was to examine the distribution of 3-m usual walk, five repeated chair stands, and three static balance stance performances among age and gender subgroups of adults at least 65 years in two national data sets. We secondarily determined whether demographic-function associations varied across data sets, birth cohorts, or models incorporating data from those "unable to do" tasks.

METHODS

Two nationally representative data sets were used to generate survey weight-adjusted performance distributions: the 2015-2016 National Social Life Health and Aging Project and the 2016 National Health and Aging Trends Study. We then regressed walk and chair stand performance on age, gender, and race/ethnicity, examining differences across data sets, birth cohorts (1920-1947, 1948-1965), and before/after incorporating the "unable to do" performers.

RESULTS

Findings confirmed the gradual decline in function with age and allowed estimation of "relative" performance within age/gender subgroups. Data set distribution differences were noted, possibly due to recruitment, eligibility, and protocol variations. Demographic associations were similar across data sets but generally weaker among the 1948-1965 cohort and in models including the sizable "unable to do" group.

DISCUSSION

We present the largest, most current Short Physical Performance Battery reference data in U.S. adults aged 65 or older. Findings support standardization of administration protocols in research and clinical care and differentiating absolute from relative performance.

Psychological and Social Factors Associated with Coexisting Frailty and Cognitive Impairment: A Systematic Review

Those living with coexistent frailty and cognitive impairment are at risk of poorer health outcomes. Research often focuses on identifying biological factors. This review sought to identify the association psychological and social factors have with coexisting physical and cognitive decline. Six databases were systematically searched in July 2020. Studies included individuals aged 60 years or older identified as being both frail and cognitively impaired. A narrative synthesis examined patterns within the data. Nine studies were included, most employed a cross-sectional design. Depression was investigated by all nine studies, those with coexistent frailty and cognitive impairment had higher levels of depressive symptoms than peers. Findings were mixed on social factors, although broadly indicate lower education, living alone and lower material wealth were more frequent in those living with coexistent decline. Further research is needed to explore potentially modifiable psychological and social factors which could lead to the development of supportive interventions.

The relationship between deprivation and frailty trajectories over 1 year and at the end of life: a case-control study

BACKGROUND

We investigated the association between area-level, multi-domain deprivation and frailty trajectories in the last year of life and over 1 year in a matched non-end-of-life sample.

METHODS

A 1-year longitudinal case-control study using primary care electronic health records from 20 460 people age ≥ 75. Cases (died 1 January 2015 to 1 January 2016) were 1:1 matched to controls by age, sex and practice location. Monthly interval frailty measured using a 36-item electronic frailty index (eFI: range 0-1, lower scores mean less frailty). Deprivation measured using Index of Multiple Deprivation (IMD) quintiles. We used latent growth curves to model the relationship between IMD and eFI trajectory.

RESULTS

Living in a less deprived area was associated with faster increase in eFI for cases (0.005% per month, 95%confidence interval [CI]: 0.001, 0.010), but not controls, and was associated with lower eFI at study baseline in cases (-0.29% per IMD quintile, 95%CI -0.45, -0.13) and controls (-0.35% per quintile, 95%CI -0.51, -0.20).

CONCLUSIONS

Overall, greater area-level deprivation is associated with higher levels of frailty, but people who survive to ≥75 have similar 1-year frailty trajectories, regardless of area-level deprivation. Interventions to reduce frailty should target younger age groups, especially those living in the most deprived areas.

Partner loss and its effect on frailty trajectories: results from the 13-year follow-up Survey of Health, Ageing and Retirement in Europe (SHARE)

BACKGROUND

Frailty is a geriatric syndrome closely linked to a variety of adverse health outcomes. Thus, it is important to identify factors associated with the development of frailty. It was the aim of this study to examine, if, and to what extent partner loss, a highly stressful life event, affects frailty trajectories of community dwelling adults aged 50 or older.

METHODS

Using six waves of panel data from the Survey of Health, Ageing and Retirement in Europe (SHARE), we investigated the effect of partner loss on frailty trajectories estimating growth curve models. Our sample included 183 502 observations of 83 494 community-dwelling individuals aged 50 or older from 21 European countries collected between 2004 and 2017. Frailty was measured using the validated sex-specific SHARE-Frailty-Instrument including muscular weakness, unintended weight loss, decrease in walking capacity, low physical activity and exhaustion.

RESULTS

Our sample contained 79 874 participants who lived in a partnership during their entire observational period and 3620 participants who lost their partner during their observational period. Both men (β=0.184 (95% CI: -0.017 to 0.386), p=0.073) and women (β=0.237 (95% CI: 0.106 to 0.369), p<0.001) showed initial effects of partner loss on frailty, but while only women gradually recovered over time (β=-0.023 (95% CI: -0.039 to -0.008), p=0.002), among men, the effect of partner loss persisted (β<0.001 (95% CI: -0.029 to 0.029), p=0.998).

CONCLUSION

This study revealed that partner loss is followed by elevated frailty. However, while women's frailty tended to recover from partner loss over time, men's frailty remained elevated. Notable individual differences in the response of frailty trajectories to partner loss suggest the existence of effect modifiers.

Trajectories of phenotypical frailty over a decade in young-old community-dwelling adults: results from the Lc65+ study

BACKGROUND

Few studies have examined the frailty trajectories of young-old adults using Fried frailty phenotype. Dropouts due to death were rarely taken into account. This longitudinal study aimed to identify trajectories with and without adjustment for non-random attrition and to analyse related factors.

METHODS

We used the first two samples of community-dwelling people in the Lausanne cohort 65+. Frailty phenotype was assessed at age 66-71 years and every third year over 10 years. A group-based trajectory modelling-first without and then with adjustment for non-random attrition-identified trajectories among all individuals with at least two observations (n=2286), excluding dropouts for reasons other than death. Multinomial logistic regressions estimated independent effects of participants' baseline characteristics.

RESULTS

We identified three frailty trajectories (low, medium and high). Participants in the highest trajectory had a higher mortality over 10 years. (Pre)frailty at baseline was the main factor associated with adverse trajectories. Smoking, obesity, comorbidity and negative self-perceived health were associated with unfavourable trajectories independently of baseline frailty, while social engagement was related to the lowest frailty trajectory. Ignoring transitions to death attenuated the estimated effects of age on trajectories.

CONCLUSIONS

Fried frailty phenotype should be assessed in individuals aged late 60s as it is strongly associated with frailty trajectories in the following decade of their life. Lifetime prevention of behavioural risk factors such as smoking and obesity is the strategy most likely to influence the development of frailty in older populations. Furthermore, our results underline social engagement as an important area of interest for future research.

Early-Life Socioeconomic Position and the Accumulation of Health-Related Deficits by Midlife in the 1958 British Birth Cohort Study

Reducing population levels of frailty is an important goal, and preventing its development in midadulthood could be pivotal. There is limited evidence on associations between childhood socioeconomic position (SEP) and frailty. Using data on the 1958 British birth cohort (followed from 1958 to 2016; n = 8,711), we aimed to 1) establish the utility of measuring frailty in midlife, by examining associations between a 34-item frailty index at age 50 years (FI_50y) and mortality at ages 50–58 years, and 2) examine associations between early-life SEP and FI_50y and investigate whether these associations were explained by adult SEP. Hazard ratios for mortality increased with increasing frailty; for example, the sex-adjusted hazard ratio for the highest quintile of FI_50y versus the lowest was 4.07 (95% confidence interval (CI): 2.64, 6.25). Lower early-life SEP was associated with higher FI_50y. Compared with participants born in the highest social class, the estimated total effect on FI_50y was 42.0% (95% CI: 35.5, 48.4) for participants born in the lowest class, with the proportion mediated by adult SEP being 0.45% (95% CI: 0.35, 0.55). Mediation by adult SEP was negligible for other early-life SEP classes. Findings suggest that early-life SEP is associated with frailty and that adult SEP only partially explains this association. Results highlight the importance of improving socioeconomic circumstances across the life course to reduce inequalities in midlife frailty.

The degree of frailty as a translational measure of health in aging

Frailty is a multiply determined, age-related state of increased risk for adverse health outcomes. We review how the degree of frailty conditions the development of late-life diseases and modifies their expression. The risks for frailty range from subcellular damage to social determinants. These risks are often synergistic-circumstances that favor damage also make repair less likely. We explore how age-related damage and decline in repair result in cellular and molecular deficits that scale up to tissue, organ and system levels, where they are jointly expressed as frailty. The degree of frailty can help to explain the distinction between carrying damage and expressing its usual clinical manifestations. Studying people-and animals-who live with frailty, including them in clinical trials and measuring the impact of the degree of frailty are ways to better understand the diseases of old age and to establish best practices for the care of older adults.

Frailty differences across population characteristics associated with health inequality: a cross-sectional analysis of baseline data from the Canadian Longitudinal Study on Aging (CLSA)

OBJECTIVE

To evaluate the pattern of frailty across several of social stratifiers associated with health inequalities.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional baseline data on 51 338 community-living women and men aged 45-85 years from the population-based Canadian Longitudinal Study on Aging (collected from September 2011 to May 2015) were used in this study.

PRIMARY OUTCOMES AND MEASURES

A Frailty Index (FI) was constructed using self-reported chronic conditions, psychological function and cognitive status and physical functioning variables. Social stratifiers were chosen based on the Pan-Canadian Health Inequalities Reporting Initiative, reflecting key health inequalities in Canada. Unadjusted and adjusted FIs and domain-specific FIs (based on chronic conditions, physical function, psychological/cognitive deficits) were examined across population strata.

RESULTS

The overall mean FI was 0.13±0.08. It increased with age and was higher in women than men. Higher mean FIs were found among study participants with low income (0.20±0.10), who did not complete secondary education (0.17±0.09) or had low perceived social standing (0.18±0.10). Values did not differ by Canadian province of residence or urban/rural status. After simultaneously adjusting for population characteristics and other covariates, income explained the most heterogeneity in frailty, especially in younger age groups; similar patterns were found for men and women. The average frailty for people aged 45-54 in the lowest income group was greater than that for those aged 75-85 years. The heterogeneity in the FI among income groups was greatest for the psychological/cognitive domain.

CONCLUSIONS

Our results suggest that especially in the younger age groups, psychological/cognitive deficits are most highly associated with both overall frailty levels and the gradient in frailty associated with income. If this is predictive of later increases in the other two domains (and overall frailty), it raises the question whether targeting mental health factors earlier in life might be an effective approach to mitigating frailty.

Trends in Frailty and Its Association With Mortality: Results From the Longitudinal Aging Study Amsterdam, 1995-2016

The aim of this study was to investigate trends in frailty and its relationship with mortality among older adults aged 64–84 years across a period of 21 years. We used data from 1995 to 2016 from the Longitudinal Aging Study Amsterdam. A total of 7,742 observations of 2,874 respondents in the same age range (64–84 years) across 6 measurement waves were included. Frailty was measured with a 32-item frailty index, with a cutpoint of ≥0.25 to indicate frailty. The outcome measure was 4-year mortality. Generalized estimating equation analyses showed that among older adults aged 64–84 years the 4-year mortality rate declined between 1995 and 2016, while the prevalence of frailty increased. Across all measurement waves, frailty was associated with 4-year mortality (odds ratio = 2.79, 95% confidence interval: 2.39, 3.26). There was no statistically significant interaction effect between frailty and time on 4-year mortality, indicating a stable association between frailty and mortality. In more recent generations of older adults, frailty prevalence rates were higher, while excess mortality rates of frailty remained the same. This is important information for health policy-makers and clinical practitioners, showing that continued efforts are needed to reduce frailty and its negative health consequences.

Frailty and socioeconomic status: a systematic review

The relationship between frailty and socioeconomic status has been widely explored in the literature. A deeper understanding toward the underlying mechanism is required to further assist policy makers in reducing the inequalities. The objective of this study is to systematically review evidence investigating the direct relationship between frailty and socioeconomic status. The review was conducted following the principles of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Among the included studies, 52.38% explored the pattern of frailty in age and 42.86% explored mediators as the pathway variables. With various measures and methodologies, included studies did not point to the same conclusions. In terms of the pattern of frailty in age, we found evidence for the age as leveller hypothesis, the status maintenance hypothesis and the cumulative advantage hypothesis. The included mediators differed across studies. However, we found that these mediators can be categorised into behaviours, health, social factors, material resources and mental status. These categories indicate the important aspects to consider for policies aiming at reducing the inequalities in frailty. To obtain a full picture of the underlying mechanism, future research should harmonise different measures for frailty and socioeconomic indicators and apply more comprehensive sets of mediators.

Two European Examples of Acute Geriatric Units Located Outside of a General Hospital for Older Adults With Exacerbated Chronic Conditions

OBJECTIVE

Throughout Europe, the number of older adults requiring acute hospitalization is increasing. Admission to an acute geriatric unit outside of a general hospital could be an alternative. In this model of acute medical care, comprehensive geriatric assessment and rehabilitation are provided to selected older patients. This study aims to compare patients' diagnoses, characteristics, and outcomes of 2 European sites where this care occurs.

DESIGN

Exploratory cohort study.

SETTING AND PARTICIPANTS

Subacute Care Unit (SCU), introduced in 2012 in Barcelona, Spain, and the Acute Geriatric Community Hospital (AGCH), introduced in 2018 in Amsterdam, the Netherlands. The main admission criteria for older patients were acute events or exacerbations of chronic conditions, hemodynamic stability on admission, and no requirement for complex diagnostics.

MEASURES

We compared setting, characteristics, and outcomes between patients admitted to the 2 units.

RESULTS

Data from 909 patients admitted to SCU and 174 to AGCH were available. Patients were admitted from the emergency department or from home. The mean age was 85.8 years [standard deviation (SD) = 6.7] at SCU and 81.9 years (SD = 8.5) (P < .001) at AGCH. At SCU, patients were more often delirious (38.7% vs 22.4%, P < .001) on admission. At both units, infection was the main admission diagnosis. Other diagnoses included heart failure or chronic obstructive pulmonary disease. Five percent or less of patients were readmitted to general hospitals. Average length of stay was 8.8 (SD = 4.4) days (SCU) and 9.9 (SD = 7.5) days (AGCH).

CONCLUSIONS AND IMPLICATIONS

These acute geriatric units are quite similar and both provide an alternative to admission to a general hospital. We encourage the comparison of these units to other examples in Europe and suggest multicentric studies comparing their performance to usual hospital care.

Inequality in hospitalization due to non-communicable diseases in Sweden: Age-cohort analysis of the Uppsala Birth Cohort Multigenerational Study

We aimed to investigate cohort differences in age trajectories of hospitalization due to non-communicable conditions, and if these varied by paternal socioeconomic position. We used the Uppsala Birth Cohort Multigenerational Study—including virtually complete information on medical diagnoses.

Our sample constituted 28,448 individuals (103,262 observations). The outcome was five-year prevalence of hospitalization due to major non-communicable conditions in 1989–2008. The exposures were age (19–91), year-of-birth (1915–1929; 1938–1972), gender (man vs woman), and parental socioeconomic position (low, medium, and high). We used multilevel logit models to examine associations between exposures and the hospitalization outcome.

Younger cohorts had a higher prevalence of hospitalization at overlapping ages than those born earlier, with inter-cohort differences emerging from early-adulthood and increasing with age. For instance, at age 40 predicted probability of hospitalization increased across birth-cohorts—from 1.2% (born in 1948-52) to 2.0% (born in 1963-67)—whereas at age 50 it was 2.9% for those born in 1938-42 compared with 4.6% among participants born in 1953-57. Those with medium and low socioeconomic position had 13.0% and 20.0% higher odds of experiencing hospitalization during the observation period, respectively—when age, year-of-birth and gender were accounted for.

We found that no progress was made in reducing the socioeconomic inequalities in hospitalization across cohorts born between 1915 and 1972. Hence, more effective policies and interventions are needed to reduce the overall burden of morbidity—particularly among the most vulnerable.

•

What is already known on this subject?

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The evidence on trends in morbidity in Sweden is mainly cross-sectional and focused on individual conditions.

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Rates of various indicators of morbidity (e.g. poor mobility, psychological distress, disability) have increased over time.

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What this study adds.

•

Successively younger birth cohorts had a higher prevalence of hospitalization, with differences emerging in early-adulthood.

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Those in medium and low parental socioeconomic position (vs high) had 13% and 20% higher odds of hospitalization.

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No progress was made in reducing the socioeconomic inequalities across cohorts born between 1915 and 1972.

The Prevalence of Frailty Using Three Different Frailty Measurements in Two Finnish Cohorts Born Before and After the Second World War

OBJECTIVES

To study the prevalence of frailty and its relationship to mortality in cohorts born before and after the Second World War using three different frailty measures.

METHODS

Cross-sectional data from two cohorts born in 1935 (n=593) and 1945 (n=714) were studied for frailty at the mean age of 70.7 (SD 1.8) years. Frailty was measured using the Frailty Phenotype (FP), the Frail Scale (FS) and the 74-item Frailty Index (FI>0.21 denoted frailty). Information on socioeconomic factors was obtained via a study questionnaire and the data on mortality were obtained from the Population Information System.

RESULTS

The prevalence of frailty by FI was more common in the older 1935 cohort than in the 1945 cohort (p<0.001). The percentage of robust subjects was higher in both sexes in the 1945 cohort using both FI and FS. After adjusting for sociodemographic factors, the difference in the prevalence of frailty between the cohorts remained significant in women only (OR 1.9 (95% CI 1.3-2.9), p=0.001). The FI classified people as frail more often (30.2% in the 1935 cohort and 17.5% in the 1945 cohort) than the FS (13.1% and 8.8%) or FP (1.8% and 1.6%). Low financial satisfaction was associated significantly with frailty in both sexes. Low level of education was associated with frailty in women and being unmarried or divorced in men. Frailty was associated to increased mortality using all frailty definitions in the 1935 cohort with a longer follow-up time.

CONCLUSIONS

Improved living conditions and health care may have resulted in the lower prevalence of frailty in the 1945 cohort. The present study further strengthens the association between frailty and mortality and poor economic status and frailty. Frailty definitions are in need of further study.

Putting cumulative (dis)advantages in context: Comparing the role of educational inequality in later-life functional health trajectories in England and Germany

BACKGROUND

The cumulative (dis)advantage (CAD) perspective more and more is examined in a comparative way, to highlight the role of context in generating inequality over the life course. This study adds to this field of research by examining trajectories of activities of daily living (ADL) in later life by educational level in a country comparison of England and Germany, emphasizing differing institutional conditions.

METHOD

Data used are the English Longitudinal Study of Ageing (ELSA; 11,352 individuals) and the German subsample of the Survey of Health and Retirement in Europe (SHARE; 5,573 individuals). Using population averaged Poisson panel regression models, 12-year trajectories of six birth cohorts are investigated, covering the age range of 50 to 90 years.

RESULTS

Respondents in England have a higher level of limitations at age 50, and more limited increases over age than in Germany. An educational gradient exists in both countries at age 50. Notably, the educational gradient increases for more recently born cohorts, but declines with increasing age in England, while in Germany educational differences increase for more recently born cohort only.

DISCUSSION

The current study indicates that CAD processes between educational groups are context sensitive. While England showed convergence of disparities with increasing age, in Germany no differential development was found.

Normative Estimates and Agreement Between 2 Measures of Health-Related Quality of Life in Older People With Frailty: Findings From the Community Ageing Research 75+ Cohort

BACKGROUND

Previous studies have summarized evidence on health-related quality of life for older people, identifying a range of measures that have been validated, but have not sought to present results by degree of frailty. Furthermore, previous studies did not typically use quality-of-life measures that generate an overall health utility score. Health utility scores are a necessary component of quality-adjusted life-year calculations used to estimate the cost-effectiveness of interventions.

METHODS

We calculated normative estimates in mean and standard deviation for EQ-5D-5L, short-form 36-item health questionnaire in frailty (SF-36), and short-form 6-dimension (SF-6D) for a range of established frailty models. We compared response distributions across dimensions of the measures and investigated agreement using Bland-Altman and interclass correlation techniques.

RESULTS

The EQ-5D-5L, SF-36, and SF-6D scores decrease and their variability increases with advancing frailty. There is strong agreement between the EQ-5D-5L and SF-6D across the spectrum of frailty. Agreement is lower for people who are most frail, indicating that different components of the 2 instruments may have greater relevance for people with advancing frailty in later life. There is a greater risk of ceiling effects using the EQ-5D-5L rather than the SF-6D.

CONCLUSIONS

We recommend the SF-36/SF-6D as an appropriate measure of health-related quality of life for clinical trials if fit older people are the planned target. In trials of interventions involving older people with increasing frailty, we recommend that both the EQ-5D-5L and SF36/SF6D are included, and are used in sensitivity analyses as part of cost-effectiveness evaluation.

Life Course Socioeconomic Conditions and Frailty at Older Ages

OBJECTIVES

This article aimed to assess associations of childhood socioeconomic conditions (CSC) with the risk of frailty in old age and whether adulthood socioeconomic conditions (ASC) influence this association.

METHODS

Data from 21,185 individuals aged 50 years and older included in the longitudinal Survey of Health, Ageing, and Retirement in Europe were used. Frailty was operationalized as a sum of presenting weakness, shrinking, exhaustion, slowness, or low activity. Confounder-adjusted multilevel logistic regression models were used to analyze associations of CSC and ASC with frailty.

RESULTS

While disadvantaged CSC was associated with higher odds of (pre-)frailty in women and men (odds ratio [OR] = 1.73, 95% confidence interval [CI] 1.34, 2.24; OR = 1.84, 95% CI 1.27, 2.66, respectively), this association was mediated by ASC. Personal factors and demographics, such as birth cohort, chronic conditions, and difficulties with activities of daily living, increased the odds of being (pre-)frail.

DISCUSSION

Findings suggest that CSC are associated with frailty at old age. However, when taking into account ASC, this association no longer persists. The results show the importance of improving socioeconomic conditions over the whole life course in order to reduce health inequalities in old age.

A Systematic Review of Frailty Trajectories: Their Shape And Influencing Factors

BACKGROUND AND OBJECTIVES

Frailty describes an increased vulnerability to adverse events such as disease or injury. Combatting this state remains a major challenge for geriatric research. By exploring how and why frailty changes throughout later life we will be better positioned to improve ways of identifying and treating those at high risk.

RESEARCH DESIGN AND METHODS

We systematically reviewed publications that captured rate of frailty progression over time and established any associated risk or protective factors that affected this progression. We included longitudinal observational studies which quantified frailty trajectories in adults aged 50+ using any validated continuous frailty measurement tool.

RESULTS

After screening 8,318 publications, 25 met our criteria. Findings show that despite a great degree of heterogeneity in the literature, progression of frailty is unquestionably affected by numerous risk and protective factors, with particular influence exhibited by social demographics, brain pathology, and physical co-morbidities.

DISCUSSION AND IMPLICATIONS

Findings that the gradient of frailty progression is affected by various influencing factors are valuable to clinicians and policymakers as will help identify those at highest frailty risk and inform prevention strategies. However, the heterogeneous methodological approaches of the publications included in this review highlights the need for consensus within the field to promote more coordinated research. Improved consistency of methods will enable further data synthesis and facilitate a greater understanding of the shape of frailty over time and the influencing factors contributing to change, the results of which could have crucial implications for frailty risk reduction.

Global frailty: The role of ethnicity, migration and socioeconomic factors

Frailty is an important consequence of ageing, whereby frail patients are more likely to face adverse outcomes, such as disability and death. Risk of frailty increases in people with poor biological health, and has been shown in many ethnicities and countries. In economically developed countries, 10% of older adults are living with frailty. Ethnic minorities in the West face significant health inequalities. However, little is known about frailty prevalence and the nature of frailty in different ethnic groups. This has implications for healthcare planning and delivery, especially screening and the development of interventions. Global frailty prevalence is variable: low- to middle-income countries demonstrate higher rates of frailty than high-income countries, but available evidence is low. Little is known about the characteristics of these differences. However, female sex, lower economic status, lower education levels, and multimorbidity are identified risk factors. Ethnic minority migrants in economically developed countries demonstrate higher rates of frailty than white indigenous older people and are more likely to be frail when younger. Similar patterns are also seen in indigenous ethnic minority marginalised groups in economically developed countries such as the US, Australia and New Zealand, who have a higher prevalence of frailty than the majority white population. Frailty trajectories between ethnic minority migrants and white indigenous groups in high-income countries converge in the 'oldest old' age group, with little or no difference in prevalence. Frailty risk can be attenuated in migrants with improvements in integration, citizenship status, and access to healthcare. Ethnicity may play some role in frailty pathways, but, so far, the evidence suggests frailty is a manifestation of lifetime environmental exposure to adversity and risk accumulation.

Country-level welfare-state measures and change in wellbeing following work exit in early old age: evidence from 16 European countries

Background

Although the effects of individual-level factors on wellbeing change following work exit have been identified, the role of welfare-state variables at the country level has yet to be investigated.

Methods

Data on 8037 respondents aged 50 years and over in 16 European countries were drawn from the Survey of Health, Ageing and Retirement in Europe (SHARE) and the English Longitudinal Study of Ageing (ELSA). We employed multilevel models to assess determinants of change in wellbeing following work exit, using CASP-12 change scores. After adjusting for institutionally defined route and timing of work exit, in addition to other individual-level variables, we tested country-level variables including welfare-state regime and measures of disaggregated welfare spending to determine their associations with wellbeing change and the proportion of between-country variance explained.

Results

Individuals whose exit from paid work was involuntary or diverged from the typical retirement age experienced declines in wellbeing. Country effects accounted for 7% of overall variance in wellbeing change. Individuals residing in countries with a Mediterranean welfare regime experienced more negative changes in wellbeing, with a difference of –2.15 (–3.23, –1.06) CASP-12 points compared with those in Bismarckian welfare states. Welfare regime explained 62% of between-country variance. National per-capita expenditure on non-healthcare in-kind benefits (services) was associated with more positive wellbeing outcomes.

Conclusions

National expenditure on in-kind benefits, particularly non-healthcare services, is associated with more favourable wellbeing change outcomes following work exit in early old age. Welfare-state effects explain the majority of between-country differences in change in wellbeing.

The times we are born into and our lifestyle choices determine our health trajectories in older age - Results from the KORA-Age study

Health projections often extrapolate from observations in current ageing cohorts, but health in older age may depend not only on individual characteristics but also on a person's historical context. Our objective was to investigate how health deficit accumulation trajectories after age 65 differed in five adjacent birth cohorts and according to individual life course characteristics. Data originate from the 2008/09 KORA (Cooperative Health Research in the Region of Augsburg)-Age cohort study from Southern Germany and their 2012 and 2016 follow-ups. Deficit accumulation was assessed using a Frailty Index. The effects of birth cohort membership and individual life course characteristics on deficit accumulation trajectories were analyzed using generalized linear mixed models. Out of 2701 participants (49% male) from five birth cohorts (1919-23, 1924-28, 1929-33, 1934-38, 1939-43), we included 2512 individuals with 5560 observations. Frailty Index levels were higher for women, smokers, alcohol abstainers, obese participants and persons with a sedentary lifestyle or living below the poverty threshold. We found higher age-specific Frailty Index levels for the two most recent birth cohorts (e.g. 61%, CI: [13%; 130%] for the 1934-38 as compared to the 1919-23 cohort), but the rate of deficit accumulation with age (7% per life year, (CI: [5%, 9%]) was cohort-independent. Results indicate that the historical context (birth cohort membership) may influence the number of accumulated health deficits after age 65 in addition to poverty and other individual life course characteristics, but BMI, physical activity and smoking remain the modifiable risk factors offering the highest prevention potential.