Combination of the clock drawing test with the physical phenotype of frailty for the prediction of mortality and other adverse outcomes in older community dwellers without dementia

Prognostic value of cognitive impairment, assessed by the Clock Drawing Test, in emergency department patients presenting with non-specific complaints

BACKGROUND

Cognitive impairment (CI) is common among older patients presenting to the emergency department (ED). The failure to recognize CI at ED presentation constitutes a high risk of additional morbidity, mortality, and functional decline. The Clock Drawing Test (CDT) is a well-established cognitive screening test.

AIM

In patients presenting to the ED with non-specific complaints (NSCs), we aimed to investigate the usability of the CDT and its prognostic value regarding length of hospital stay (LOS) and mortality.

METHOD

Secondary analysis of the Basel Non-specific Complaints (BANC) trial, a prospective delayed type cross-sectional study with a 30-day follow-up. In three EDs, patients presenting with NSCs were enrolled. The CDT was administered at enrollment.

RESULTS

In the 1,278 patients enrolled, median age was 81 [74, 87] years and 782 were female (61.19%). A valid CDT was obtained in 737 (57.7%) patients. In patients without a valid CDT median LOS was higher (29 [9, 49] days vs. 22 [9, 45] days), and 30-day mortality was significantly higher than in patients with a valid CDT (n = 45 (8.32%) vs. n = 39 (5.29%)). Of all valid CDTs, 154 clocks (20.9%) were classified as normal, 55 (7.5%) as mildly deficient, 297 (40.3%) as moderately deficient, and 231 (31.3%) as severely deficient. Mortality and LOS increased along with the CDT deficits (p = 0.012 for 30-day mortality; p < 0.001 for LOS).

CONCLUSION

The early identification of patients with CI may lead to improved patient management and resource allocation. The CDT could be used as a risk stratification tool for older ED patients presenting with NSCs, as it is a predictor for 30-day mortality and LOS.

Comprehensive review: Frailty in pancreas transplant candidates and recipients

Well-selected patients with kidney disease and diabetes mellitus who undergo simultaneous kidney-pancreas transplantation often experience dramatic improvements in quality of life and long-term survival compared to those who remain on medical therapy. Over the past several years the importance of frailty in the pancreas transplant candidate and recipient populations has grown. More patients with advanced age have entered the waitlist, and complications from prolonged diabetes, even in younger patients, have created increased evidence of risk for frailty. Given these concerns, and the broad challenges facing pancreas transplantation volumes overall, we generated this review to help establish the impact and implications. We summarize the interplay of immunological factors, aging, environmental factors, diabetes mellitus, and chronic kidney disease that put these patients at risk for frailty. We discuss its measurement and recommend a combination of two instruments (both well-validated and one entirely objective). We describe the outcomes for patients before and after pancreas transplantation who may have frailty, and what interventions can be taken to mitigate its effects. Broader investigation into frailty in the pancreas transplant population is needed to better understand how to select patients for pancreas transplantation and to how manage its consequences thereafter.

The effect of sex and physical frailty on incident disability after 2 years among community-dwelling older adults: KFACS study

Background

This study investigated the impact of physical frailty on the development of disabilities in mobility, activities of daily living (ADL), and instrumental activities of daily living (IADL) according to sex among community-dwelling Korean older adults.

Methods

We used data of 2,905 older adults aged 70-84 years from the Korean Frailty and Aging Cohort Study (KFACS) at baseline (2016-2017) and Wave 2 (2018-2019). Fried’s physical frailty phenotype was used to identify frailty.

Results

After adjustment, frailty showed a higher impact for women than men on developing mobility disability (odds ratio [OR]=14.00, 95% confidence interval [CI]=4.8–40.78 vs. OR=9.89, 95% CI=4.28–22.86) and IADL disability after two years (OR=7.22, 95% CI=2.67–19.56 vs. OR=3.19, 95% CI=1.17–8.70). Pre-frailty led to mobility disability for women and men (OR=2.77, 95% CI=1.93–3.98 vs. OR=2.49, 95% CI=1.66–3.72, respectively), and IADL disability only for women (OR=3.01, 95% CI=1.28–7.09). Among the IADL components, both men and women who were prefrail or frail showed increased disability in ‘using transportation’. Among men, pre-frailty was significantly associated with disability in “going out” and “shopping”. In women, frailty was significantly associated with disability in “doing laundry,” “performing household chores,” “shopping,” and “managing money”.

Conclusions

Physical frailty increased disability over 2 years for women more than men. Physical frailty increased disability in outdoor activity-related IADL components in men and household work-related IADL components in women. This study highlights the need for gender-specific policies and preventative programs for frailty, particularly restorative interventions that focus on women who are physically frail.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03263-5.

Clinical and Objective Cognitive Measures for the Diagnosis of Cognitive Frailty Subtypes: A Comparative Study

Background

Cognitive frailty (CF) includes reversible and potentially reversible subtypes; the former is known as concurrent physical frailty (PF) and pre-mild cognitive impairment subjective cognitive decline (pre-MCI SCD), whereas the latter is known as concurrent PF and MCI. The diagnoses of pre-MCI SCD and MCI are based on clinical criteria and various subjective cognitive decline questionnaires. Heterogeneous assessment of cognitive impairment (CI) results in significant variability of CI, CF, and their subtype prevalence in various population-based studies.

Objective

This study aimed to compare the classification differences in CI and CF subtypes from PF and normal cognition by applying clinical and objective cognitive criteria. Clinical criteria comprised Fried PF and clinical MCI criteria combined with the SCD questionnaire, whereas objective criteria comprised Fried PF and objective cognitive criteria based on the norm-adjusted six neuropsychological test scores.

Methods

Of the 335 volunteers (age ≥ 60 years) in this study, 191 were diagnosed with CI based on clinical cognitive diagnosis criteria, and 144 were identified as robust normal based on objective cognitive assessment from the community-dwelling older adult cohort. Individuals with clinical CI, including 94 with MCI and 97 with pre-MCI SCD, were reclassified into different z-score-derived MCI, pre-MCI SCD, and normal subgroups based on objective cognitive criteria. The classification diagnostic accuracy of normal cognition, PF, pre-MCI, MCI, CF, and CF subtypes based on clinical and objective criteria was compared before and after adjusting for age, sex, and education level.

Results

The reclassification of objective assessments indicated better performance than that of clinical assessments in terms of discerning CI severity among different subgroups before adjusting for demographic factors. After covariate adjustment, clinical assessments significantly improved the ability to cognitively discriminate normal individuals from those with pre-MCI SCD and MCI but not the z-score-derived pre-MCI SCD and MCI groups from the robust normal group. Furthermore, the adjustment did not improve the ability to discriminate among individuals with reversible CF from those with potentially reversible CF and pre-MCI only SCD from MCI only SCD.

Conclusions

Objective criteria showed better performance than clinical criteria in the diagnosis of individuals with CI or CF subtypes. Rapid clinical cognitive screening in combination with normative z-scores criteria is cost effective and sustainable in clinical practice.

Five-Meter Walk Test as a Predictor of Prolonged Index Hospitalization After Transcatheter Aortic Valve Implantation

There are no studies evaluating comprehensive predictors of transcatheter aortic valve implantation (TAVI) outcomes encompassing frailty assessments in a South-East Asian cohort. In this longitudinal single-center cohort, all patients who underwent TAVI in a tertiary cardiac center and comprehensively assessed for frailty at baseline were included in a registry. The primary outcome was to investigate frailty indices predictive of prolonged index hospitalization after TAVI. Seventy-six patients with a mean age of 77.6 ± 8.5 years were included. Mean Society of Thoracic Society Predicted Risk of Mortality score was 5.2 ± 3.0, with 11 (14.5%) patients classified as high-risk (Society of Thoracic Society Predicted Risk of Mortality >8). Mean and median index hospitalization duration were 9.2 ± 5.6 and 7 [4.5 to 9.5] days, respectively. Univariate analysis demonstrated that lower hemoglobin (Hb) (p <0.01), longer 5-meter walk test (5MWT) (p <0.01), lower dominant hand grip strength (p <0.01), the use of transaortic access (p = 0.01), new atrial fibrillation post-TAVI (p <0.01), and lower postprocedural Hb (p <0.01) were associated with longer index hospitalization duration. Multivariate linear regression demonstrated preoperative Hb, preoperative atrial fibrillation and 5MWT were independent baseline predictors of index hospitalization duration (p <0.05). Additionally, a 5MWT cutoff of 11 seconds (0.45 m/s) had a high specificity (88.6%) in predicting prolonged index hospitalization duration. In conclusion, this is the first comprehensive frailty assessment in a South-East Asian cohort demonstrating 5MWT to be a significant predictor of prolonged index hospitalization. This simple and effective frailty assessment index may be considered to optimize patient selection for TAVI.

Understated Cognitive Impairment Assessed with the Clock-Drawing Test in Community-Dwelling Individuals Aged ≥50 Years

OBJECTIVES

To estimate the prevalence of understated cognitive impairment by administering the Clock-Drawing Test (CDT) to community-dwelling individuals aged ≥50 years and to investigate the associated clinical phenotype.

DESIGN

A cross-sectional analysis of baseline data on community-dwelling individuals assessed at an outpatient clinic in the Paris region of France.

SETTING AND PARTICIPANTS

Participants aged ≥50 years (n = 488, median age: 62.1 years) prospectively included in the SUCCessful agEing outpatiEnt's Department survey between 2010 and 2014.

METHODS

A multidimensional geriatric assessment, including cognition [7-point CDT, Mini-Mental State Examination (MMSE), the 5-word screening test (5-WT), and the Frontal Assessment Battery (FAB)], gait speed in dual tasks, mood [the Geriatric Depression Scale (GDS)], balance, physical functions (gait speed and handgrip strength), nutrition, bone density, and comorbidities; major cardiovascular risk factors, and Scheltens and Fazekas scores on brain magnetic resonance imaging. Baseline characteristics were analyzed as a function of the CDT score (<7 vs 7), using age-adjusted logistic models.

RESULTS

The prevalence of impairment in the CDT was 23.6%; higher than the values for the MMSE (12.7%), 5-WT (2.3%), and FAB (16.6%). In age-adjusted analyses, a lower educational level (odds ratio [95% confidence interval] = 0.72 [0.58‒0.89]), diabetes (2.57 [1.14‒5.79]), metabolic syndrome (1.93 [1.05‒3.56]), lower gait speed in the cognitive dual task (1.27 [1.05‒1.53]), a poorer Geriatric Depression Scale score (1.86 [1.04‒3.32]), a poorer MMSE score (2.56 [1.35‒4.88]), a poorer FAB score (1.79 [1.01‒3.16]), impaired episodic memory in the 5-WT (4.11 [1.12‒15.02]), and a higher Scheltens score (P = .001) were significantly associated with CDT impairment.

CONCLUSIONS AND IMPLICATIONS

Understated cognitive impairment is common among young seniors and is associated with factors known to be linked to a higher risk of cognitive decline and dementia. These findings suggest that the CDT may be of value for identifying high-risk individuals who may then benefit from targeted multidomain prevention actions (diet, exercise, cognitive training, and vascular risk factor management).

Stratifying risk for dementia onset using large-scale electronic health record data: A retrospective cohort study

INTRODUCTION

Preventing dementia, or modifying disease course, requires identification of presymptomatic or minimally symptomatic high-risk individuals.

METHODS

We used longitudinal electronic health records from two large academic medical centers and applied a validated natural language processing tool to estimate cognitive symptomatology. We used survival analysis to examine the association of cognitive symptoms with incident dementia diagnosis during up to 8 years of follow-up.

RESULTS

Among 267,855 hospitalized patients with 1,251,858 patient years of follow-up data, 6516 (2.4%) received a new diagnosis of dementia. In competing risk regression, an increasing cognitive symptom score was associated with earlier dementia diagnosis (HR 1.63; 1.54-1.72). Similar results were observed in the second hospital system and in subgroup analysis of younger and older patients.

DISCUSSION

A cognitive symptom measure identified in discharge notes facilitated stratification of risk for dementia up to 8 years before diagnosis.

Association between frailty and incident risk of disability in community-dwelling elder people: evidence from a meta-analysis

OBJECTIVE

Frailty is considered to be one of the risk factors of disability. However, the results of original reported studies are not consistent with respect to the frailty and incidence of disability, and previously published meta-analyses have also shown inconsistent results. This meta-analysis was conducted to investigate the relationship between the different stages of frailty and the incidence of disability by examining updated overall trends in community-dwelling elders.

STUDY DESIGN

Cohort studies in English or Chinese based on associations between frailty and incident disability risks that were published from 2000 until the current date were researched using PubMed, Embase, Web of Science, and CENTRAL databases.

METHODS

The Q test and I² statistic were used to examine between-study heterogeneity. Random-effect models were adopted to synthesize the results based on the study heterogeneity. Subgroup analyses were also conducted to explore the possible sources of between-study heterogeneity based on the characteristics of participants.

RESULTS

Eighteen cohort studies with 88,906 participants were included in our meta-analyses. Compared with the non-frailty category, the combined relative risks (RRs) (95% confidence interval [CI]) of the disability were 1.66 (1.49-1.85) and 2.53 (2.01-3.14) for the category of prefrailty and frailty, respectively. Results suggested that the incident risk of disability at follow-up times <5 (RR = 3.19, 95% CI = 2.25-4.53) was significantly higher than for follow-up times ≥5 in the frailty category (RR = 2.00, 95% CI = 1.55-2.56). The risk in a sample size of ≥1000 (RR = 2.78, 95% CI = 2.04-3.14) was significantly higher than that when the sample size was <1000 (RR = 1.91, 95% CI = 1.53-2.37) in the frailty group. Compared with a value adjusted for comorbidity, the unadjusted comorbidity was significantly higher in the prefrailty category (1.90 vs. 1.52). Compared with a value adjusted for education, the unadjusted education was significantly higher in the prefrailty category (1.81 vs. 1.46). No publication bias was observed.

CONCLUSION

The overall meta-analysis confirms that frailty has significantly increased the incident risk of disability. Frail, elderly people are at the highest risk of future disability and may be adequate candidates for taking part in prevention and intervention programs.

Frailty, transition in frailty status and all-cause mortality in older adults of a Taichung community-based population

BACKGROUND

Previous studies have reported the associations of frailty phenotype or its components with mortality. However, studies that explored the effects of transition in frailty status on mortality were far less in Asian or Chinese. The aim of this study was to evaluate baseline frailty status and one-year change of frailty status in relation to all-cause mortality in Taiwanese community-dwelling older adults who participated in the Taichung Community Health Study for Elders.

METHODS

We conducted a community-based prospective cohort study. A total of 921 community-dwelling elderly men and women aged 65-99 years in Taichung City were enrolled in 2009-2010 and were followed up through 2016. We adopted the definition of frailty proposed by Fried et al., including five components: shrinking, weakness, poor endurance and energy, slowness, and low physical activity. Cox proportional hazards models were used to determine adjusted hazard ratios (HRs) of mortality with 95% confidence intervals (CIs) for frailty at baseline and one-year change in frailty status.

RESULTS

There were 160 deaths during the follow-up period. The mortality rates in groups of robust and frail were 20.26 and 84.66 per 1000 person-years respectively. After multivariate adjustment, the HR (CIs) for baseline frailty was 2.67 (1.73-4.12). Poor endurance and energy [1.88 (1.03-3.42)], slowness [2.60 (1.76-3.83)] and weakness [1.65 (1.16-2.33)] were found to be predictors of mortality. Increased risks in mortality for subgroups of robust-to-frail [2.76 (1.22-6.27)], frail-to-robust [3.87 (1.63, 9.19)], and frail-to-frail [4.08 (1.92-8.66)] over one-year period were observed compared with those remaining robust.

CONCLUSION

Baseline frailty status and one-year change in frailty status are associated with 6-year all-cause mortality among Taiwanese elderly adults. Frailty may be useful for identifying older adults at high risks for mortality prevention.

Frailty and Cognitive Impairment in Predicting Mortality Among Oldest-Old People

Backgrounds: Frailty and cognitive impairment are critical geriatric syndromes. In previous studies, both conditions have been identified in old-age adults as increased risk factors for mortality. However, the combined effect of these two syndromes in predicting mortality among people with advanced age is not well understood. Thus, we used Chinese community cohort to determine the impact of the combined syndromes on the oldest-old people. Methods: Our present study is part of an ongoing project on Longevity and Aging in Dujiangyan, which is a community study on a 90+ year cohort in Sichuan Province in China. Participants were elderly people who completed baseline health assessment in 2005 followed by a collection of mortality data in 2009. Frailty and cognitive function were assessed with 34-item Rockwood Frailty Index and the Mini-Mental Status Examination, respectively, and the combined effect(s) of these two parameters on death was examined using the Cox proportional hazard regression model. Results: This study consisted of a total of 705 participants (age = 93.6 ± 3.3 years; 67.4% females), of which 53.8% died during a four-year follow-up period. The prevalence of frailty, cognitive impairment, and the overlap of these two syndromes was 63.7, 74.2, and 50.3%, respectively. Our data showed that the subjects with combined frailty and cognitive impairment were associated with increased risk of death (age, gender, education level, and other potential confounders adjusted); the hazard ratio was 2.13 (95% confidence interval 1.39, 3.24), compared with the control group. However, neither frailty alone nor cognitive impairment alone increased the risk of death in these individuals. Conclusion: The combined frailty and cognitive impairment, other than the independently measured syndromes (frailty or cognitive impairment alone), was a significant risk factor for death among the oldest-old Chinese people.

Frailty and the Prediction of Negative Health Outcomes: A Meta-Analysis

INTRODUCTION

Frailty is one of the most important concerns regarding our aging population. Evidence grows that the syndrome is linked to several important health outcomes. A general overview of frailty concepts and a comprehensive meta-analysis of their relation with negative health outcomes still lacks in literature, making it difficult for health care professionals and researchers to recognize frailty and the related health risks on the one hand and on the other hand to appropriately follow up the frailty process and take substantiated action. Therefore, this study aims to give an overview of the predictive value of the main frailty concepts for negative health outcomes in community-dwelling older adults.

METHODS

This review and meta-analysis assembles prospective studies regarding the relation between frailty and any potential health outcome. Frailty instruments were subdivided into frailty concepts, so as to make comprehensive comparisons. Odds ratios (ORs), hazard ratios (HRs), and relative risk (RR) scores were extracted from the studies, and meta-analyses were conducted in OpenMeta Analyst software.

RESULTS

In total, 31 articles retrieved from PubMed, Web of Knowledge, and PsycInfo provided sufficient information for the systematic review and meta-analysis. Overall, (pre)frailty increased the likelihood for developing negative health outcomes; for example, premature mortality (OR 2.34 [1.77-3.09]; HR/RR 1.83 [1.68-1.98]), hospitalization (OR 1.82 [1.53-2.15]; HR/RR 1.18 [1.10-1.28]), or the development of disabilities in basic activities of daily living (OR 2.05 [1.73-2.44]); HR/RR 1.62 [1.50-1.76]).

CONCLUSION

Overall, frailty increases the risk for developing any discussed negative health outcome, with a 1.8- to 2.3-fold risk for mortality; a 1.6- to 2.0-fold risk for loss of activities of daily living; 1.2- to 1.8-fold risk for hospitalization; 1.5- to 2.6-fold risk for physical limitation; and a 1.2- to 2.8-fold risk for falls and fractures. The analyses presented in this study can be used as a guideline for the prediction of negative outcomes according to the frailty concept used, as well as to estimate the time frame within which these events can be expected to occur.

Additive Role of a Potentially Reversible Cognitive Frailty Model and Inflammatory State on the Risk of Disability: The Italian Longitudinal Study on Aging

OBJECTIVE

Cognitive frailty is a condition recently defined by operationalized criteria describing the simultaneous presence of physical frailty and mild cognitive impairment (MCI). Two subtypes for this clinical construct have been proposed: "potentially reversible" cognitive frailty (physical frailty plus MCI) and "reversible" cognitive frailty (physical frailty plus pre-MCI subjective cognitive decline). Here the prevalence of a potentially reversible cognitive frailty model was estimated. It was also evaluated if introducing a diagnosis of MCI in older subjects with physical frailty could have an additive role on the risk of dementia, disability, and all-cause mortality in comparison with frailty state or MCI condition alone, with analyses separately performed for inflammatory state.

METHODS

In 2,373 individuals from the population-based Italian Longitudinal Study on Aging with a 3.5-year-follow-up, we operationally categorized older individuals without dementia into four groups: non-frail/non-MCI, non-frail/MCI, frail/non-MCI, and frail/MCI.

RESULTS

The prevalence of potentially reversible cognitive frailty was 1%, increasing with age and more represented in women than in men, and all groups were associated with significant increased incident rate ratios of dementia, disability, and mortality. A significant difference in rates of disability has been found between the MCI and non-MCI groups (contrasts of adjusted predictions: 0.461; 95% confidence interval: 0.187-0.735) in frail individuals with high inflammatory states (fibrinogen >339 mg/dL).

CONCLUSION

In older individuals without dementia and with elevated inflammation, a potentially reversible cognitive frailty model could have a significant additional predictive effect on the risk of disability than the single conditions of frailty or MCI.

Cognitive Impairment and Overall Survival in Frail Surgical Patients

BACKGROUND

The definition of frailty, as modeled by the Fried criteria, has been limited primarily to the physical domain. The purpose of this study was to assess the additive value of cognitive function with existing frailty criteria to predict poor postoperative outcomes in a large multidisciplinary cohort of patients undergoing major operations.

STUDY DESIGN

A 4-level composite frailty scoring system was created via the combination of the Fried frailty score and the Emory Clock Draw Test to assess preoperative frailty and cognitive impairment, respectively. Overall survival was defined as months from date of operation to date of death or last follow-up.

RESULTS

This study included 330 patients undergoing major operations; mean age was 58 years and a total of 53 patient deaths occurred during 4-year follow-up. Among the robust cohort, 20 of 168 patients died (11.9%), and among those who were both physically frail and cognitively impaired, 11 of 26 patients died (42.3%). Multivariable analysis demonstrated the physically frail and cognitively impaired cohort to have a 3.92 higher risk of death (95% CI 1.66 to 9.26) compared with the cohort of robust patients (p = 0.002). Kaplan-Meier survival curves reveal an overall difference in long-term survival (log-rank p < 0.0001), driven mainly by the high risk of mortality among patients with both physical frailty and cognitive impairment.

CONCLUSIONS

The use of a combined frailty and cognitive assessment score has a more powerful potential to predict adult patients at higher risk of overall survival than either measurement alone. The addition of cognitive assessment to physical frailty measure can lead to improved preoperative decision making and possibly early intervention, as well as more accurate patient counseling.

Cognitive Frailty: Mechanisms, Tools to Measure, Prevention and Controversy

Physical frailty is often associated with cognitive impairment, possibly because of common underlying pathophysiologic mechanisms. To stimulate research in this field, the concept cognitive frailty was proposed, emphasizing the important role of brain aging. Cognitive frailty was defined as the presence of cognitive deficits in physically frail older persons without dementia. This subtype of frailty is deemed important, as it may represent a prodromal phase for neurodegenerative diseases and is potentially a suitable target for early intervention. The aim of this report is to refine the framework for the definition and mechanisms of cognitive frailty and relevant screening tools.

Frailty as a predictor of disabilities among community-dwelling older people: a systematic review and meta-analysis

BACKGROUND

Frailty has been shown to be associated with disability in the previous studies. However, it is not clear how consistently or to how much degree frailty is actually associated with the future disability risks.

METHODS

A systematic review of the literature was conducted using Embase, MEDLINE, CINAHL, PsycINFO, and the Cochrane Library for any prospective studies published from 2010 to September 2015 examining associations between baseline frailty status and subsequent risk of developing or worsening disabilities among community-dwelling older people. A meta-analysis was performed to synthesize pooled estimates.

RESULTS

Of 7012 studies identified through the systematic review, 20 studies were included in the meta-analysis. Twelve studies examined activities of daily living (ADL) disability risks, two studies examined instrumental activities of daily living (IADL) disability risks, and six studies examined both ADL and IADL disability risks. Overall, frail older people were more likely to develop or worsen disabilities in ADL (12 studies, pooled OR = 2.76, 95% CI = 2.23-3.44, p < 0.00001; 5 studies, pooled HR = 2.23, 95% CI = 1.42-3.49, p < 0.00001) and IADL (6 studies, pooled OR = 3.62, 95% CI = 2.32-5.64, p < 0.00001; 2 studies, pooled HR = 4.24, 95% CI = 0.85-21.28, p = 0.08). Prefrailty was also associated with incident or worsening disability risks to a lesser degree in most pooled analyses. High heterogeneity observed among 12 studies with OR of ADL disability risks for frailty was explored using subgroup analyses, which suggested methodological quality and mean age of the cohort were the possible causes.

CONCLUSION

This systematic review meta-analysis quantitatively showed that frail older people are at higher risks of disabilities. These results are important for all related parties given population aging worldwide. Interventions for frailty are important to prevent disability and preserve physical functions, autonomy, and quality of life. Implications for Rehabilitation Although frailty has been shown to be associated with disability and considered as a precursor of disability, it is not clear how consistently or to how much degree frailty is actually associated with the future disability risks. This systematic review and meta-analysis quantitatively shows frailty is a significant predictor of incident and worsening ADL and IADL disabilities. It is a pressing priority to develop interventions for frailty to prevent disability and preserve older people's physical functions, autonomy, and quality of life.

Targeting Cognitive Frailty: Clinical and Neurobiological Roadmap for a Single Complex Phenotype

Late-life cognitive disorders may be prevented by influencing age-related conditions such as frailty, characterized by decreased resistance to stressors and increased risk for adverse health outcomes. In the present review article, we examined clinical and epidemiological studies investigating the possible role of different frailty models in modulating the risk of Alzheimer's disease (AD), dementia, vascular dementia (VaD), mild cognitive impairment (MCI), and late-life cognitive impairment/decline that have been published over the past 3 years. Both deficit accumulation and physical frailty models were associated with late-life cognitive impairment/decline, incident dementia, AD, MCI, VaD, non-AD dementias, and AD pathology, proposing cognitive frailty as a new clinical construct with coexisting physical frailty and cognitive impairment in nondemented older subjects. Two subtypes of this new clinical condition have been recently proposed: "potentially reversible" cognitive frailty and "reversible" cognitive frailty. The physical factors should be physical prefrailty and frailty, while the cognitive impairment of potentially reversible cognitive frailty should be MCI (Clinical Dementia rating Scale = 0.5), while the cognitive impairment of reversible cognitive frailty should be pre-MCI Subjective Cognitive Decline (SCD), as recently proposed by the SCD Initiative Working Group. The mechanisms underlying the cognitive-frailty link are multifactorial and vascular, inflammatory, nutritional, and metabolic influences may be of major relevance. Considering both physical frailty and cognition as a single complex phenotype may be crucial in the prevention of dementia and its subtypes with secondary preventive trials on cognitive frail older subjects.

Cognitive Frailty: A Systematic Review of Epidemiological and Neurobiological Evidence of an Age-Related Clinical Condition

Advancing age is the focus of recent studies on familial and sporadic Alzheimer's disease (AD), suggesting a prolonged pre-clinical phase several decades before the onset of dementia symptoms. Influencing some age-related conditions, such as frailty, may have an impact on the prevention of late-life cognitive disorders. Frailty reflects a nonspecific state of vulnerability and a multi-system physiological change with increased risk for adverse health outcomes in older age. In this systematic review, frailty indexes based on a deficit accumulation model were associated with late life cognitive impairment and decline, incident dementia, and AD. Physical frailty constructs were associated with late-life cognitive impairment and decline, incident AD and mild cognitive impairment, vascular dementia, non-AD dementias, and AD pathology in older persons with and without dementia, thus also proposing cognitive frailty as a new clinical condition with co-existing physical frailty and cognitive impairment in non-demented older subjects. Considering both physical frailty and cognitive impairment as a single complex phenotype may be central in the prevention of dementia and its subtypes with secondary preventive trials on cognitive frail older subjects. The mechanisms underlying the cognitive-frailty link are multi-factorial, and vascular, inflammatory, nutritional, and metabolic influences may be of major relevance. There is a critical need for randomized controlled trials of intervention investigating the role of nutrition and/or physical exercise on cognitive frail subjects with the progression to dementia as primary outcome. These preventive trials and larger longitudinal population-based studies targeting cognitive outcomes could be useful in further understanding the cognitive-frailty interplay in older age.