Frailty and the Risk of Polypharmacy in the Older Person: Enabling and Preventative Approaches

Global and regional prevalence of polypharmacy and related factors, 1997-2022: An umbrella review

OBJECTIVE

Limited comprehensive evidence exists on the global prevalence of polypharmacy. This knowledge gap contributes to increased healthcare system costs and related public health concerns. Thus, we aimed to synthesize the current evidence on polypharmacy prevalence and associated factors in the general and older populations using an umbrella review.

METHODS

Our primary outcomes were global prevalence and related indicators of polypharmacy. We systematically searched Google Scholar, PubMed/MEDLINE, Embase, and CINAHL for studies published between the inception of each database until April 30, 2023.

RESULTS

Eleven meta-analyses incorporating 295 studies and 59,552,762 participants from 41 countries across six continents were identified. The global prevalence of polypharmacy in the general population is 37 %, with higher rates in older individuals (45 %), outpatients (48 %), and inpatients (52 %). North America showed a higher prevalence (52 %) than Asia (36 %) and Europe (36 %). Among frail elderly individuals, the prevalence of polypharmacy is 59 %, with the highest rates in Europe (68 %) and hospital settings (71 %).

CONCLUSION

The global prevalence of polypharmacy and its associated factors in older adults present a complex, multifaceted, and conflicting picture. Understanding the prevalence of polypharmacy and its associated factors may help reduce the number of multidrug prescriptions.

Implementation of frailty screening for older people living with HIV in Brighton, UK

OBJECTIVES

To evaluate the implementation of frailty screening in people living with HIV (PLWH) in a large urban cohort of patients in Brighton, UK.

METHODS

Focus group discussions with HIV professionals and PLWH interviews helped inform the design and implementation of the frailty screening pathway in the clinic. Data were collected from PLWH aged over 60 years attending their HIV annual health check from July 2021 to January 2023 (n = 590), who were screened for frailty by nurses using the FRAIL scale. We assessed the proportions of PLWH who screened as frail, prefrail or robust and compared patient characteristics across groups. All PLWH identified as frail were offered a comprehensive geriatric assessment delivered by a combined HIV geriatric clinic, and uptake was recorded.

RESULTS

A total of 456/590 (77.3%) PLWH aged over 60 years were screened for frailty. Median age and time since HIV diagnosis (range) for those screened were 66 (60-99) years and 21 (0-32) years, respectively. In total, 56 (12.1%) of those screened were identified as frail, 118 (25.9%) as prefrail and 282 (61.8%) as robust. A total of 10/56 (18%) people identified as frail declined an appointment in the geriatric clinic. Compared with non-frail individuals, frail PLWH had been living with HIV for longer and had a greater number of comorbidities and comedications but were not chronologically older.

CONCLUSIONS

Implementing frailty screening in PLWH over 60 years old is feasible in a large cohort of PLWH, as recommended by the European AIDS Clinical Society. More research is needed to determine if frailty screening can improve clinical outcomes of older PLWH and the use of the comprehensive geriatric assessment within HIV services.

Cultural adaptation and validation of the Sinhala version of the Frail Non-disabled tool (FiND)

BACKGROUND

Frailty, a common geriatric syndrome of vulnerability, is associated with a decline in health and function. The most problematic expression of population ageing is associated with weakness, slowing, decreased energy, lower activity and when severe, unintended weight loss. Frailty is not consciously identified in clinical practice and is not widely studied in Sri Lanka. A validated tool for screening frailty in a busy clinical setting is therefore much needed. This study was done as a part of validating the Sinhala version of the Frail Non-Disabled (S-FiND) tool.

METHODS

The FiND tool was translated from English to Sinhala by two translators, blinded to each other. They were combined and translated back to the original language by two separate translators. After verifying the content validity, unambiguity and clarity of items in a focused group discussion, the pre-final version was piloted among 30 volunteers. After assessing the psychometric properties of the pre-final version, the final version was tested among 100 adults older than 65 years from the Colombo South Teaching Hospital. The tool was compared with Fried's frailty phenotype taken as the gold standard.

RESULTS

Data were analysed for the agreement with the reference standard, the Fried Phenotype. The mean (SD) age of subjects was 73.9 (7.8) years. The overall time taken to fill out the questionnaire was 2 min. The agreement (Kappa) between the S-FiND questionnaire and the Fried phenotype was 0.7 (P < 001). The sensitivity and specificity of FiND in detecting frailty were 92% and 74%, respectively. The agreements (Kappa) between the individual items of S-Find: involuntary loss of weight/ more than 4.5 kg over one year, the feeling of effort/ not getting going and level of physical activity, with the Fried phenotype, were 0.28 (p = 0.001), 0.06 (p = 0.045) and 0.339 (p < 0.001). respectively. When subjects were categorized frail and robust based on FiND, frail subjects reported a higher incidence of falls (50%) during the previous 12 months, compared to those robust (13%) (p < 0.001 for Chi stat).

CONCLUSION

The S-FiND is a reliable, valid and well-received tool that can be used in detecting the frailty of non-disabled Sinhala-speaking older adults.

Attitudes of Older Adult Patients and Caregivers Towards Deprescribing of Medications in Ethiopia

Background

Deprescribing is essential for reducing inappropriate medication use and polypharmacy. For a holistic approach, it is essential to know how older adult patients and their caregivers perceive deprescribing.

Objective

To assess the attitude of older adult patients and caregivers towards deprescribing medication at Ambo University Referral Hospital.

Methodology

Institutional-based cross-sectional study was conducted using the revised Patients' Attitude Towards Deprescribing tool (rPATD). The data was analyzed using the SPSS-25 software. Backward linear regression and logistic regression were used to measure association between outcome and determinant variables. The two-sided P-value ≤0.05 with 95% confidence interval was utilized for reporting significant factors.

Results

One hundred fifty-six (81.3%) of the respondents (ie, 85.0% of older adult and 77.2% of caregivers) agreed to stop one or more of their regular medications if the physician said it was possible despite 98 (51.0%) of them (ie, 49.0% of older adult and 53.3% of caregivers) being satisfied with their/their care recipient's medications. On the overall aggregate mean score, the respondents had a neutral position (2.6-3.59) regarding the burden and concerns of stopping medications whereas the majority of them disagree (1.0-2.59) with the inappropriateness of the medication they were taking and agreed (3.6-5.0) with the need for their involvement in treatment decision making. Concerns about stopping medicine scores (AOR = 0.440, 95% CI = 0.262-0.741, P = 0.035) and perceived levels of medication inappropriateness (AOR = 0.653, 95% CI = 0.456-0.936, P = 0.020) was significantly associated with the willingness to discontinue and overall satisfaction with their medicine regimen respectively.

Conclusion

The majority of older adult patients and caregivers would like to deprescribe if the physicians recommended it. The perceived concerns of stopping and inappropriateness of the medicines were associated with the willingness to deprescribe and overall satisfaction with their medicine respectively. Healthcare providers should prompt the deprescribing process with older adult patients and caregivers by addressing their concerns about stopping medications.

Medication Assessment in an Older Population during Acute Care Hospitalization and Its Effect on the Anticholinergic Burden: A Prospective Cohort Study

(1) Background: Anticholinergic and sedative drugs (ASDs) contribute to negative health outcomes, especially in the frail population. In this study, we aimed to assess whether frailty increases with anticholinergic burden and to evaluate the effects of medication reviews (MRs) on ASD regimens among patients attending an acute care for the elderly (ACE) unit. (2) Methods: A cohort study was conducted between June 2019 and October 2020 with 150 consecutive patients admitted to our ACE unit. Demographic, clinical, and pharmacological data were assessed. Frailty score was determined using the Frail-VIG index (FI-VIG), and ASD burden was quantified using the drug burden index (DBI). In addition, the MR was performed using the patient-centered prescription (PCP) model. We used a paired T-test to compare the DBI pre- and post-MR and univariate and multivariate regression to identify the factors associated with frailty. (3) Results: Overall, 85.6% (n = 128) of participants showed some degree of frailty (FI-VIG > 0.20) and 84% (n = 126) of patients received treatment with ASDs upon admission (pre-MR). As the degree of frailty increased, so did the DBI (p < 0.001). After the implementation of the MR through the application of the PCP model, a reduction in the DBI was noted (1.06 ± 0.8 versus 0.95 ± 0.7) (p < 0.001). After adjusting for covariates, the association between frailty and the DBI was apparent (OR: 11.42, 95% (CI: 2.77-47.15)). (4) Conclusions: A higher DBI was positively associated with frailty. The DBI decreased significantly in frail patients after a personalized MR. Thus, MRs focusing on ASDs are crucial for frail older patients.

Age and Breast Reconstruction

BACKGROUND

Breast reconstruction is frequently offered to cancer patients who undergo mastectomy. Older women tend to have lower rates of reconstruction mostly due to an age-based discretion. We aimed to assess the safety of this surgery in this population.

METHODS

We conducted a single-center retrospective analysis of patients who underwent breast reconstruction following mastectomy between 2015 and 2020 at "Complejo Hospitalario Universitario de Albacete." Patients were classified according to age when the reconstruction process began (group A: < 65 years-group B: > 65 years). Differences in demographics and clinical data were analyzed using Student's t test and Chi-square test. Multivariable logistic regression models were used to estimate odds ratio (OR) and confidence intervals (CIs) for surgical complications according to age group. Propensity-score matching was used as a sensitivity analysis to test consistency among results.

RESULTS

We included 304 women (266: group A-38: group B). Complete reconstruction was achieved in 48.1% of patients in group A vs 10.5% in group B (P < 0.001). After adjusting for potential confounders, age was not associated with an increased risk of surgical complications, neither overall (OR 0.88, 95%CI 0.40-1.95), early (OR 1.35, 95%CI 0.58-3.13) nor late (OR 1.05, 95%CI 0.40-2.81). Radiotherapy and smoking history were significant predictors for complications in every setting.

CONCLUSIONS

In our cohort, age at breast reconstruction is not associated with a higher risk of surgical complications, in contrast to radiotherapy and smoking history. Therefore, age should not be a limiting factor when considering breast reconstruction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Polypharmacy, chronic kidney disease, and mortality among older adults: A prospective study of National Health and nutrition examination survey, 1999-2018

Introduction

Polypharmacy might contribute to a range of adverse outcomes, which could get worse in the elderly with chronic kidney disease (CKD). Evidence on polypharmacy, CKD, and mortality is scarce. We aimed to investigate the prospective association between polypharmacy, CKD and all-cause and cause-specific mortality in adults aged ≥65 years.

Methods

A total of 13,513 adults from the National Health and Nutrition Examination Surveys were included, following up from 1999 to 2018 until December 31, 2019. The simultaneous use of ≥5 medications by one individual was defined as polypharmacy. Survey-weighted Cox proportional hazard models were used to estimate the hazard ratio (HRs) for mortality from all-cause, cardiovascular diseases (CVD), and cancer after adjusting for potential confounding factors.

Results

Among the elderly with CKD, we identified 3,825 total deaths (1,325 CVD and 714 cancer) during a median follow-up of 7.7 years. Participants with polypharmacy had a 27% (HR = 1.27 [1.15, 1.39]) and 39% (HR = 1.39 [1.19, 1.62]) higher risk of all-cause and CVD mortality, respectively, but not for cancer mortality. Compared with the elderly with no polypharmacy and no CKD, the corresponding HRs (95%CIs) for all-cause mortality were 1.04 (0.96, 1.14) for those with no polypharmacy but CKD, 1.24 (1.11, 1.39) for with polypharmacy but no CKD, and 1.34 (1.21, 1.49) for those with both polypharmacy and CKD. A similar pattern was detected for CVD mortality.

Discussion

Polypharmacy was associated with elevated risks of all-cause and CVD mortality among the elderly CKD patients. More evidence-based approaches should be promoted for the appropriate deprescribing in the older adults with CKD.

Prevalence and health outcomes of polypharmacy and hyperpolypharmacy in older adults with frailty: A systematic review and meta-analysis

Polypharmacy is a prevalent issue in older adults, associated with a wide range of adverse health outcomes, amplified in those with frailty. This review aims to synthesize current literature on the prevalence and health outcomes of polypharmacy and hyperpolypharmacy in older adults with frailty. A systematic search was carried out within ten databases till December 2021. Data was extracted using a piloted data extraction form, and methodological quality was assessed using JBI critical appraisal checklists. Meta-analyses were conducted for prevalence, and narrative synthesis was conducted for the health outcomes of polypharmacy and hyperpolypharmacy in older adults with frailty. Heterogeneity was assessed using Chi² and I² statistics, with sensitivity and subgroup analyses performed to explore sources of heterogeneity. Sixty-six studies were included for this review. The overall pooled prevalence of polypharmacy and hyperpolypharmacy was 59% and 22% respectively. When stratifying the studies by setting, WHO regions, in eighteen frailty assessment instruments, and by its year of publication, subgroup analysis found the highest rates of prevalence in the hospital setting (71%), in the European region (68%), when Reported Edmonton Frail Scale was used (96%), and in studies published in 2015 (86%). Additionally, frail older adults with polypharmacy were less likely to experience an improvement in frailty states, had higher risks of mortality, were more likely to suffer adverse hospital-related outcomes, and required additional assistance compared to those without polypharmacy. Therefore, the high prevalence and poorer health outcomes urges the healthcare providers and health policymakers to develop and implement preventative and restorative measures targeted at the adverse outcomes associated with polypharmacy and hyperpolypharmacy in older adults with frailty.

Development of a shared decision-making intervention to improve drug safety and to reduce polypharmacy in frail elderly patients living at home

Objectives

For patients with geriatric frailty, reducing inappropriate medication is an important goal to improve patient safety in primary care. GP-side barriers include knowledge gaps, legal concerns, and lack of communication between the actors involved. The aim was to develop a multi-faceted intervention to facilitate deprescribing and shared prioritisation among frail elderlies with polypharmacy living at home.

Methods

Mixed methods study including: 1) scoping review on family conferences, expert panels; 2) group discussions with GPs, mapping of needs and challenges in Primary Care; 3) workshops and expert interviews with GPs, patient advocates, researchers as a basis for a theoretical intervention model; 4) piloting.

Results

A major challenge for GPs is to conduct a productive discussion with patients and family cares on deprescribing and drug safety. A guideline for a structured family conference with a medication check and geriatric assessment was developed and proved to be feasible in the pilot study.

Conclusion

The intervention developed to facilitate deprescribing and shared prioritisation of drug therapy based on family conferences seems suitable to be tested in a subsequent cRCT.

Innovation

Adapting family conferences to primary care for frail patients with polypharmacy.

The Feasibility of Deriving the Electronic Frailty Index from Australian General Practice Records

Purpose

Frailty is a prevalent condition in older adults. Identification of frailty using an electronic Frailty Index (eFI) has been successfully implemented across general practices in the United Kingdom. However, in Australia, the eFI remains understudied. Therefore, we aimed to (i) examine the feasibility of deriving an eFI from Australian general practice records and (ii) describe the prevalence of frailty as measured by the eFI and the prevalence with socioeconomic status and geographic remoteness.

Participants and Methods

This retrospective analysis included patients (≥70 years) attending any one of >700 general practices utilizing the Australian MedicineInsight data platform, 2017–2018. A 36-item eFI was derived using standard methodology, with frailty classified as mild (scores 0.13–0.24); moderate (0.25–0.36) or severe (≥0.37). Socioeconomic status (Socio-Economic Indexes for Areas (SEIFA) index)) and geographic remoteness (Australian Statistical Geography Standard (ASGC) remoteness areas) were also examined.

Results

In total, 79,251 patients (56% female) were included, mean age 80.0 years (SD 6.5); 37.4% (95% CI 37.0–37.7) were mildly frail, 16.7% (95% CI 16.4–16.9) moderately frail, 4.8% (95% CI 4.7–5.0) severely frail. Median eFI score was 0.14 (IQR 0.08 to 0.22); maximum eFI score was 0.69. Across all age groups, moderate and severe frailty was significantly more prevalent in females (P < 0.001). Frailty severity increased with increasing age (P < 0.001) and was strongly associated with socioeconomic disadvantage (P < 0.001) but not with geographic remoteness.

Conclusion

Frailty was identifiable from routinely collected general practice data. Frailty was more prevalent in socioeconomically disadvantaged groups, women and older patients and existed in all levels of remoteness. Routine implementation of an eFI could inform interventions to prevent or reduce frailty in all older adults, regardless of location.

Potentially Inappropriate Medications among Elderly with Frailty in a Tertiary Care Academic Medical Centre in Saudi Arabia

This study aims to assess the prevalence of potentially inappropriate medications (PIMs) and to analyze the relationship between the PIMs and frailty among inpatient older adults aged 65 and above in Saudi Arabia. A retrospective cross-sectional study design was utilized during the period between April 2021 and April 2022 of all patients aged 65 years and above admitted in a public tertiary hospital in Saudi Arabia. Data on the number of medications and the use of PIMs were assessed using Beers’ criteria while the frailty status was assessed using the “FRAIL Scale”. Of the 358 patient files that were reviewed, 52.2% were males, 60.9% were aged 65−74 years, and 82% were married. The prevalence of robust, prefrail, and frail patients was 5%, 36.9%, and 58.1%, respectively. According to the 2019 Beers criteria, a total of 45.8% (n = 164) participants identified as using PIMs. Compared to the non-PIMs group, the PIMs group demonstrated significant differences in the number of medications (p < 0.001), the number of comorbidities (p < 0.05), and the frailty score (p < 0.001). The strongest predictor of PIM use was a number of comorbidities, recording an odds ratio of 2.86, (95% CI 1.21−6.77, p < 0.05). Our results show that the use of PIM was significantly associated with frail older adults with multiple comorbidities and in patients with polypharmacy. A clear assessment and evaluation tool may improve the quality of drug treatment in the older adult population, particularly in frail patients.

Polypharmacy and Cardiovascular Diseases: Consideration for Older Adults and Women

PURPOSE OF REVIEW

The intent of this review is to provide an update in polypharmacy in older adults and women with a focus on common determinants and strategies to mitigate polypharmacy.

RECENT FINDINGS

Polypharmacy is becoming a critical focus in the management of cardiovascular diseases. It may emerge unintentionally while managing multimorbidity in older adults or in the vulnerable subgroup of patients, such as pregnant and lactating females. Clinicians should utilize several approaches such as deprescribing, sex-specific risk assessment, and encouraging healthy lifestyle to minimize inappropriate and unnecessary use of medications. A shared decision-making model along with coordination and collaboration among healthcare providers should be utilized in the selection and management of pharmacotherapies.

Adverse drug reactions, multimorbidity and polypharmacy: a prospective analysis of 1 month of medical admissions

OBJECTIVE

To ascertain the burden and associated cost of adverse drug reactions (ADRs), polypharmacy and multimorbidity through a prospective analysis of all medical admissions to a large university teaching hospital over a 1-month period.

DESIGN

Prospective observational study.

SETTING

Liverpool University Hospital Foundation National Health Service (NHS) Trust, England.

PARTICIPANTS

All medical admissions with greater than 24-hour stay over a 1-month period.

MAIN OUTCOME MEASURES

Prevalence of admissions due to an ADR and associated mortality, prevalence and association of multimorbidity and polypharmacy with ADRs, and estimated local financial cost of admissions where an ADR was a contributing or main reason for admission with projected costs for NHS in England.

RESULTS

There were 218 identified patient admissions with an ADR giving a prevalence of 18.4%. The majority of these (90.4%) were ADRs that directly resulted in or contributed to admission. ADRs thus accounted for 16.5% of total admissions. Those with an ADR were on average taking more medicines (10.5 vs 7.8, p<0.01) and had more comorbidities than those without an ADR (6.1 vs 5.2, p<0.01). Drugs most commonly implicated were diuretics, steroid inhalers, anticoagulants and antiplatelets, proton pump inhibitors, chemotherapeutic agents and antihypertensives. 40.4% of ADRs were classified avoidable or possibly avoidable. The mortality rate due to an ADR was 0.34%. The average length of stay for those with an ADR was 6 days. Direct 1-month cost to the Trust from ADR admissions was £490 716. Extrapolated nationally, the projected annual cost to the NHS in England is 2.21 billion.

CONCLUSION

The local prevalence of admission and mortality from ADRs is higher than previously reported. Important factors that could be contributing to this include polypharmacy and multimorbidity. ADRs place a significant burden on patients and healthcare services with associated financial implications. Reducing inappropriate polypharmacy should be a major aim for preventing ADRs.

The association between polypharmacy, frailty and disability-free survival in community-dwelling healthy older individuals

OBJECTIVES

Polypharmacy and frailty are two common geriatric conditions. In community-dwelling healthy older adults, we examined whether polypharmacy is associated with frailty and affects disability-free survival (DFS), assessed as a composite of death, dementia, or persistent physical disability.

METHODS

We included 19,114 participants (median age 74.0 years, IQR: 6.1 years) from ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial. Frailty was assessed by a modified Fried phenotype and a deficit accumulation Frailty Index (FI). Polypharmacy was defined as concomitant use of five or more prescription medications. Multinomial logistic regression was used to examine the cross-sectional association between polypharmacy and frailty at base line, and Cox regression to determine the effect of polypharmacy and frailty on DFS over five years.

RESULTS

Individuals with polypharmacy (vs. <5 medications) were 55% more likely to be pre-frail (Relative Risk Ratio or RRR: 1.55; 95%Confidence Interval or CI:1.44, 1.68) and three times more likely to be frail (RRR: 3.34; 95%CI:2.64, 4.22) according to Fried phenotype. Frailty alone was associated with double risk of the composite outcome (Hazard ratio or HR: 2.16; 95%CI: 1.56, 2.99), but frail individuals using polypharmacy had a four-fold risk (HR: 4.24; 95%CI: 3.28, 5.47). Effect sizes were larger when frailty was assessed using the FI.

CONCLUSION

Polypharmacy was significantly associated with pre-frailty and frailty at baseline. Polypharmacy-exposed frailty increased the risk of reducing disability-free survival among older adults. Addressing polypharmacy in older people could ameliorate the impact of frailty on individuals' functional status, cognition and survival.

Physical Condition and Risk of Hospitalization and Polypharmacy in Older Adults

Hospitalization in older population leads to a decline in physical function, physical condition and independency. However, a scarce number of studies has addressed the effect of being in good physical condition on the risk of hospitalization and polypharmacy in older people. Therefore, this study aims to examine the relationship between physical condition and other health factors, and the incidence of hospitalization and polypharmacy in Spanish older persons. For this cross-sectional study 102 community-dwelling persons aged 80 years or older who were being treated at three primary care centers. The data collected were number of hospitalizations and medications, dietary habits, nutrition status, quality of life, independence in activities of daily life, physical performance and associated genotype data. Scoring higher in the tests Chair stand and 8-Foot Up-and-go was found associated with reduced risks of hospitalization [OR = .45 (95% CI = .2, .99); OR .32 (95% CI = .12, .86)] and polypharmacy [OR = .36 (95% CI = .16, .8); OR= .28 (95% CI = .1, .78)]. The number of medications was also lower in individuals with a greater aerobic capacity and activities of daily life independence [OR = .28 (95% CI = .1, .78); OR = .37 (95% CI = .16, .82)]. No associations were found with the remaining physical performance tests or other factors assessed. Our findings point to benefits of greater strength, balance and aerobic capacity in terms of reducing the risk of hospitalization and polypharmacy.

Integrated Care Components in Transitional Care Models from Hospital to Home for Frail Older Adults: A Systematic Review

Introduction

Frail older adults frequently experience transitions from hospital to home due to their complex care needs. Transitional care models (TCMs) are recommended to tackle adverse outcomes in frail patients. This review summarizes the use of integrated care components in addressing transitional care from hospital to home, provides an overview on reported outcomes and describes the impact of identified components on the outcomes hospital readmission and emergency department visit.

Methods

This study is part of the European TRANS-SENIOR project. PubMed, CINAHL and Embase were searched for studies in English, German and Dutch that describe a TCM for frail older patients including both pre- and post-discharge components.

Results

Seventeen studies, covering 15 TCMs were included. All TCMs describe a person-centred, tailored, pro-active and continuous transitional care service. Components like a small sized care team, intensive follow-up, shared decision making and informal caregiver involvement are likely to be associated with reduced hospital readmission and ED visits. Twenty-seven transitional care outcomes were reported: 19 service outcomes, six patient outcomes and two provider outcomes.

Conclusion

Heterogeneity in content and outcomes complicates between-study comparison, yet several components were identified that improved care outcomes. Patient and provider outcomes should be included in future research.

The need for long-term personalized management of frail CVD patients by rehabilitation and telemonitoring: a framework

Due to advances in cardiovascular medicine and preventive cardiology, patients benefit from a better prognosis, even in case of significant disease burden such as acute and chronic coronary syndromes, advanced valvular heart disease and chronic heart failure. These advances have allowed CVD patients to increase their life expectancy, but on the other hand also experience aging-related syndromes such as frailty. Despite being underrecognized, frailty is a critical, common, and co-existent condition among older CVD patients, leading to exercise intolerance and compromised adherence to cardiovascular rehabilitation. Moreover, frail patients need a different approach for CR and are at very high risk for adverse events, but yet are underrepresented in conventional CR. Fortunately, recent advances have been made in technology, allowing remote monitoring, coaching and supervision of CVD patients in secondary prevention programs with promising benefits. Similarly, we hypothesized that such programs should also be implemented to treat frailty in CVD patients. However, considering frail patients' particular needs and challenges, telerehabilitation interventions should thus be appropriately adapted. Our purpose is to provide, for the first time and based on expert opinions, a framework of how such a cardiac telerehabilitation program could be developed and implemented to manage a prevention and rehabilitation program for CVD patients with frailty.

Polypharmacy Is Significantly and Positively Associated with the Frailty Status Assessed Using the 5-Item FRAIL Scale, Cardiovascular Health Phenotypic Classification of Frailty Index, and Study of Osteoporotic Fractures Scale

The aim of this study was to investigate the association between frailty and polypharmacy using three different frailty screening tools. This was a cross-sectional study of people aged ≥65 years. Participants were included and interviewed using questionnaires. Polypharmacy was defined as the daily use of eight or more pills. Frailty was assessed using a screening tool, including (1) the Fatigue, Resistance, Ambulation, Illness and Loss of Weight Index (5-item FRAIL scale), (2) the Cardiovascular Health Phenotypic Classification of Frailty (CHS_PCF) index (Fried’s Frailty Phenotype), and (3) the Study of Osteoporotic Fracture (SOF) scale. A total of 205 participants (mean age: 71.1 years; 53.7% female) fulfilled our inclusion criteria. The proportion of patients with polypharmacy was 14.1%. After adjustments were made for comorbidity or potential confounders, polypharmacy was associated with frailty on the 5-item FRAIL scale (adjusted odds ratio [aOR]: 9.12; 95% confidence interval [CI]: 3.6–23.16), CHS_PCF index (aOR: 8.98; 95% CI: 2.51–32.11), and SOF scale (aOR: 6.10; 95% CI: 1.47–25.3). Polypharmacy was associated with frailty using three frailty screening tools. Future research is required to further enhance our understanding of the risk of frailty among older adults.

Prevalence and Incidence of Frailty Among Community-dwelling Older Adults in Slovenia

INTRODUCTION

Frailty is recognized as one of the most important global health challenges as the population is aging. The aim of this study was to evaluate prevalence and incidence of frailty, and associated factors, among the population of older adults in Slovenia compared to other European countries.

METHODS

The prevalence and 4-year incidence of frailty among older adults (≥65 years) were evaluated using data from the Survey of Health, Ageing and Retirement in Europe (SHARE). Frailty was defined by the SHARE operationalization of Frailty phenotype. Multiple logistic regression model was used to explore factors associated with frailty.

RESULTS

Age-standardized prevalence (95% CI) of frailty and pre-frailty in Slovenia were 14.9% (13.3-16.5) and 42.5% (39.8-45.2), respectively. Factors (OR, 95% CI) associated with increased frailty in Slovenia included age (7584 years: 5.03 (3.08-8.22); ≥85 years 21.7 (10.6-44.7) vs. 65-74 years), self-rated health (fair: 4.58 (2.75-7.61), poor: 54.6 (28.1-105.9) vs. excellent/very good/good), number of chronic diseases (1.20 (1.03-1.40)), and polypharmacy (yes: 3.25 (1.93-5.48) vs. no). Female gender and lower education were significantly associated with pre-frailty, but not frailty, in the adjusted model. Independently of these characteristics, age-standardized prevalence of frailty varied among geographical regions. Age-standardized 4-year incidence of frailty and pre-frailty in Slovenia were 6.6% (3.0-10.1) and 40.2% (32.7-47.6), respectively.

CONCLUSION

Among the Slovenian population of older adults aged 65 years and older, the age-standardized prevalence of frailty is 15% and 4-year incidence of frailty is 7%. Regional differences in Slovenia show the lowest prevalence in central Slovenian regions and the highest in northeastern Slovenian regions.

Frailty and HIV: Moving from Characterization to Intervention

PURPOSE OF REVIEW

While the characteristics associated with frailty in people with HIV (PWH) have been well described, little is known regarding interventions to slow or reverse frailty. Here we review interventions to prevent or treat frailty in the general population and in people with HIV (PWH).

RECENT FINDINGS

Frailty interventions have primarily relied on nonpharmacologic interventions (e.g., exercise and nutrition). Although few have addressed frailty, many of these therapies have shown benefit on components of frailty including gait speed, strength, and low activity among PWH. When nonpharmacologic interventions are insufficient, pharmacologic interventions may be necessary. Many interventions have been tested in preclinical models, but few have been tested or shown benefit among older adults with or without HIV. Ultimately, pharmacologic and nonpharmacologic interventions have the potential to improve vulnerability that underlies frailty in PWH, though clinical data is currently sparse.

Frailty and Its Associated Risk Factors: First Phase Analysis of Multicentre Indonesia Longitudinal Aging Study

Background: National long-term care development requires updated epidemiological data related to frailty. We aimed to find the prevalence of frailty and its associated factors among Indonesian elderly.

Methods: We conducted first-phase cross-sectional analysis of Indonesia Longitudinal Aging Study (INALAS) data collected from community-dwelling outpatients aged 60 years and older without acute illness in nine geriatric service care centres. Descriptive, bivariate and multivariate analyses were conducted.

Results: Among 908 elderly in this study, 15.10% were robust, 66.20% were pre-frail, and 18.70% were frail. Functional dependence was associated with frailty among Indonesian elderly (OR 5.97, 95% CI 4.04–8.80). Being depressed and at risk for malnutrition were also associated with frailty with OR 2.54, 95% CI 1.56–4.12, and OR 2.56, 95% CI 1.68–3.90, respectively. Prior history of fall (OR 1.77, 95% CI 1.16–2.72) and hospitalization (OR 1.46, 95% CI 0.97–2.20) in the previous 12 months were associated with frailty. There is also significant association between poly pharmacy and frailty (OR 2.42, 95% CI 1.50–3.91).

Conclusion: Approximately one in five Indonesian community-dwelling elderly was frail. Frailty is associated with functional dependence, being at risk for malnutrition or being malnourished, depression, history of fall, history of hospitalization, and poly pharmacy. There may be bidirectional relationships between the risk factors and frailty. The development of long-term care in Indonesia should be considered, without forcing the elderly who need it.

Identifying Glycemic Variability in Diabetes Patient Cohorts and Evaluating Disease Outcomes

Glycemic variability (GV) is an obstacle to effective blood glucose control and an autonomous risk factor for diabetes complications. We, therefore, explored sample data of patients with diabetes mellitus who maintained better amplitude of glycemic fluctuations and compared their disease outcomes with groups having poor control. A retrospective study was conducted using electronic data of patients having hemoglobin A1C (HbA1c) values with five recent time points from Think Whole Person Healthcare (TWPH). The control variability grid analysis (CVGA) plot and coefficient of variability (CV) were used to identify and cluster glycemic fluctuation. We selected important variables using LASSO. Chi-Square, Fisher’s exact test, Bonferroni chi-Square adjusted residual analysis, and multivariate Kruskal–Wallis tests were used to evaluate eventual disease outcomes. Patients with very high CV were strongly associated (p < 0.05) with disorders of lipoprotein (p = 0.0014), fluid, electrolyte, and acid–base balance (p = 0.0032), while those with low CV were statistically significant for factors influencing health status such as screening for other disorders (p = 0.0137), long-term (current) drug therapy (p = 0.0019), and screening for malignant neoplasms (p = 0.0072). Reducing glycemic variability may balance alterations in electrolytes and reduce differences in lipid profiles, which may assist in strategies for managing patients with diabetes mellitus.

Inflammatory Activities in Type 2 Diabetes Patients With Co-morbid Angiopathies and Exploring Beneficial Interventions: A Systematic Review

Background: Diabetes is a long-term condition that can be treated and controlled but do not yet have a cure; it could be induced by inflammation and the goal of managing it is to prevent additional co-morbidities and reduce glycemic fluctuations. There is a need to examine inflammatory activities in diabetes-related angiopathies and explore interventions that could reduce the risk for future outcome or ameliorate its effects to provide insights for improved care and management strategies.

Method: The study was conducted in Embase (1946–2020), Ovid Medline (1950–2020), and PubMed databases (1960–2020) using the PICO framework. Primary studies (randomized controlled trials) on type 2 diabetes mellitus and inflammatory activities in diabetes-related angiopathies were included. Terms for the review were retrieved from the Cochrane library and from PROSPERO using its MeSH thesaurus qualifiers. Nine articles out of 454 total hits met the eligibility criteria. The quality assessment for the selected study was done using the Center for Evidence-Based Medicine Critical Appraisal Sheet.

Results: Data analysis showed that elevated CRP, TNF-α, and IL-6 were the most commonly found inflammatory indicator in diabetes-related angiopathies, while increased IL-10 and soluble RAGE was an indicator for better outcome. Use of drugs such as salsalate, pioglitazone, simvastatin, and fenofibrate but not glimepiride or benfotiamine reported a significant decrease in inflammatory events. Regular exercise and consumption of dietary supplements such as ginger, hesperidin which have anti-inflammatory properties, and those containing prebiotic fibers (e.g., raspberries) revealed a consistent significant (p < 0.05) reduction in inflammatory activities.

Conclusion: Inflammatory activities are implicated in diabetes-related angiopathies; regular exercise, the intake of healthy dietary supplements, and medications with anti-inflammatory properties could result in improved protective risk outcome for diabetes patients by suppressing inflammatory activities and elevating anti-inflammatory events.

Multi-Morbidity in the Older Person: An Examination of Polypharmacy and Socioeconomic Status

There has been increased focus on clinically managing multi-morbidity in the older population, but it can be challenging to find appropriate paradigm that addresses the socio-economic burden and risk for polypharmacy. The Commission on Social Determinants of Health (CSDH) has examined the need for institutional change and the parallel need to address the social causes of poor health. This study explored three potential interventions namely, meaningful information from electronic health records (EHR), social prescribing, and redistributive welfare policies from a person-centered perspective using the CARE (connecting, assessing, responding, and empowering) approach. Economic instruments that immediately redistribute state welfare and reduce income disparity such as direct taxation and conditional cash transfers could be adopted to enable older people with long-term conditions have access to healthcare services. Decreased socioeconomic inequality and unorthodox prescriptive interventions that reduce polypharmacy could mitigate barriers to effectively manage the complexities of multi-morbidity.