Physical Frailty and Cognitive Impairment in Older Adults in United States Nursing Homes

Independent and combined associations of depression and cognitive impairment with frailty in oldest-old adults

BACKGROUND

Frailty is one of the most significant issues related to human aging. Although studies have confirmed the association of mental and cognitive disorders with frailty, the association might be influenced by age, since oldest-old adults are more likely to have adverse health outcomes. Thus, this study aimed to examine independent and combined associations of mental health and cognitive function with frailty in oldest-old adults using data from the Chinese Longitudinal Healthy Longevity Survey in 2018.

METHODS

A sum of 6,891 and 3,171 older adults aged 80 and older were included in this study when analyzing the association of depression and cognitive impairment with frailty, respectively. Frailty was measured by the Study of Osteoporotic Fractures frailty index, depression was assessed by the Center for Epidemiologic Studies Depression Scale, and cognitive impairment was evaluated by the Chinese version of modified Mini-Mental State Examination. Independent sample t-test, Chi-square tests, and logistic regression analyses were used to examine the associations of depression and cognitive impairment with frailty.

RESULTS

Older persons with depression or cognitive impairment had a higher chance of frailty. The adjusted odds ratio (OR) of frailty was 1.27 (95% CI: 1.01, 1.59, p = 0.044) in those with depression, and 1.85 (95% CI: 1.14, 3.01, p = 0.013) in those with cognitive impairment. Compared to adults who had neither depression nor cognitive impairment, those with either depression or cognitive impairment, and those with both depression and cognitive impairment had a significantly higher likelihood of frailty (adjusted OR: 1.61, 95% CI: 1.07, 2.41; and adjusted OR: 4.03, 95% CI: 2.05, 7.94).

CONCLUSIONS

The findings suggest that depression and cognitive impairment are associated with frailty. The concurrence of depression and cognitive impairment has an additive effect on frailty in oldest-old population.

The effects of cognitive leisure activities on frailty transitions in older adults in China: a CHARLS-Based longitudinal study

BACKGROUND

In an effort to identify factors associated with frailty transitions that trigger a significant difference in preventing and postponing the progression of frailty, questions regarding the role of cognitive leisure activities on various aspects of older adults' health were raised. However, the relationship between cognitive leisure activities and frailty transitions has rarely been studied.

METHODS

A total of 5367 older Chinese adults aged over 60 years from the China Health and Retirement Longitudinal Study (CHARLS) were selected as participants. The 2nd wave of the CHARLS in 2013 was selected as the baseline, and sociodemographic and health-related status baseline data were collected. The FRAIL Scale was used to measure frailty, while cognitive leisure activities were measured by the Cognitive Leisure Activity Index (CLAI) scores, which consisted of playing mahjong or cards, stock investment, and using the internet. After two years of follow-up, frailty transition from baseline was assessed at the 3rd wave of the CHARLS in 2015. Ordinal logistic regression analysis was used to examine the relationship between cognitive leisure activities and frailty transitions.

RESULTS

During the two-year follow-up of 5367 participants, the prevalence of frailty that improved, remained the same and worsened was 17.8% (957/5367), 57.5% (3084/5367) and 24.7% (1326/5367), respectively. Among all participants, 79.7% (4276/5367), 19.6% (1054/5367), and 0.7% (37/5367) had CLAI scores of 0, 1, and 2 to 3, respectively. In the univariate analysis, there was a statistically significant association between a score of 2 to 3 on the Cognitive Leisure Activity Index and frailty transitions (odds ratio [OR] = 1.93, 95% CI 0.03 to 1.29, p = .04), while all other covariates were not significantly different across the three groups. After adjusting for covariates, participants with more cognitive leisure activities had a higher risk of frailty improvement than those without cognitive leisure activities (odds ratio [OR] = 1.99, 95% CI 1.05 to 3.76, p = .04).

CONCLUSIONS

Cognitive leisure activities were positively associated with the risk of frailty improvement in older adults, mainly when participating in multiple such activities. Older adults may be encouraged to participate in a wide variety of cognitive leisure activities to promote healthy aging.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association between serum omega-3 PUFAs levels and cognitive impairment in never medically treated first-episode patients with geriatric depression: A cross-sectional study

BACKGROUND

Geriatric depression increases the public health burden and health care costs, reduces quality of life. Studies have shown the association between ω-3 PUFAs levels and inflammatory markers levels and depression, but few have explored the relationship between omega-3 PUFAs, inflammatory markers, and cognitive function in geriatric depression. This study aimed to compare the differences in ω-3 PUFAs levels and inflammatory markers between geriatric depression with cognitive impairment (CI) and those without CI.

METHODS

A total of three hundred and five elderly patients were recruited. In addition to collecting basic information, their blood specimens were collected to detect serum EPA, DHA, AA, TC, LDL-C, IL-6, TNF-α, and hs-CRP levels. The Hamilton depression scale (HAMD), Hamilton anxiety scale (HAMA), and The Montreal cognitive assessment (MoCA) were used to assess their depression, anxiety, and cognitive function, respectively.

RESULTS

Compared to those without CI, geriatric depression patients with CI had higher serum TC, LDL-C levels, lower EPA, DHA, and AA levels, and more elevated IL-6, TNF-α, and hs-CRP levels (all P < 0.05). Further linear regression analysis showed that EPA, DHA, and TNF-α, hs-CRP levels were significantly associated with the occurrence and the severity of CI.

LIMITATIONS

No causal relationship could be drawn due to the cross-sectional design.

CONCLUSIONS

Omega-3 PUFAs and inflammatory factors levels may predict CI in elderly patients with MDD in the future. Our findings suggest that ω-3 PUFAs (EPA and DHA) and inflammatory factors (TNF-α and CRP) may predict the occurrence and the severity of CI among elderly MDD patients.

Incremental burden on health-related quality of life, health service utilization and direct medical expenditures associated with cognitive impairment among non-institutionalized people with diabetes aged 65 years and older

AIMS

To quantify the incremental health and economic burden associated with cognitive impairment (CI) among non-institutionalized people with diabetes ≥65 years in the United States.

MATERIALS AND METHODS

Using 2016-2019 Medical Expenditure Panel Surveys data, we identified participants ≥65 years with diabetes. We used propensity score weighting to quantify the CI-associated incremental burden on health-related quality of life measured by the 12-item Short Form Survey (SF-12), including the mental component summary score, physical component summary score and health utility. We also compared the annual health service utilization and expenditures on ambulatory visits, prescriptions, home care, emergency room (ER), hospitalizations and total annual direct medical expenditures.

RESULTS

We included 5094 adults aged ≥65 with diabetes, of whom 804 had CI. After propensity score weighting, CI was associated with a lower mental component summary score (-8.4, p < .001), physical component summary score (-5.2, p < .001) and health utility (-0.12, p < .001). The CI group had more ambulatory visits (+4.4, p = .004) and prescriptions (+9.9, p < .001), with higher probabilities of having home care (+11.3%, p < .001) and ER visits (+8.2%, p = .001). People with CI spent $5441 (p < .001) more annually, $2039 (p = .002) more on prescriptions, $2695 (p < .001) more on home care and $118 (p < .001) more on ER visits. There is no statistically significant difference in the utilization and expenditure of hospitalizations.

CONCLUSION

CI was associated with worse health-related quality of life, higher health service utilization and expenditures. Our findings can be used to monitor the health and economic burden of CI in non-institutionalized older persons with diabetes.

Chewing difficulty and frailty trajectories in Chinese nursing home residents: A prospective cohort study

AIM

To investigate frailty trajectories in nursing home residents, and to test whether chewing difficulty was a significant factor associated with frailty trajectories.

METHODS

This is a 1-year prospective cohort study. Data were collected from 27 nursing home residents in China at baseline, 6 months, and 12 months. Latent class growth modeling was used to identify frailty trajectories. Multilevel multinomial logistic regression was used to test the relative risk ratios (RRRs) with 95% confidence intervals (CIs) of the chewing difficulty assessed at baseline on frailty trajectories.

RESULTS

In total, 269 nursing home residents were included in the analysis. Three frailty trajectories identified were non-frailty trajectory (n = 181, 67.3%), stable frailty trajectory (n = 52, 19.3%), and progressive frailty trajectory (n = 36, 13.4%). Chewing difficulty was found among 138 (51.3%) nursing home residents. With the non-frailty trajectory group as the reference, residents with chewing difficulty were more likely to demonstrate stable frailty trajectory (RRR = 2.55, 95% CI [1.28-5.11]) or progressive frailty trajectory (RRR = 3.46, 95% CI [1.47-8.15]).

CONCLUSIONS

Changes in the frailty of nursing home residents are heterogeneous and chewing difficulty should be assessed and addressed on a routine basis in nursing homes to prevent the deterioration of frailty or reverse it. Geriatr Gerontol Int 2023; 23: 803-808.

Frailty after COVID-19: The wave after?

The COVID-19 pandemic poses an ongoing public health challenge, with a focus on older adults. Given the large number of older persons who have recovered from COVID-19 and reports of long-lasting sequelae, there is reasonable concern that the COVID-19 pandemic may lead to a long-term deterioration in the health of older adults, i.e., a potential "wave of frailty." Therefore, it is critical to better understand the circumstances surrounding the development of frailty as a result of COVID-19, as well as the underlying mechanisms and factors contributing to this development. We conducted a narrative review of the most relevant articles published on the association between COVID-19 and frailty through January 2023. Although few studies to date have addressed the effects of COVID-19 on the onset and progression of frailty, the available data suggest that there is indeed an increase in frailty in the elderly as a result of COVID-19. Regarding the underlying mechanisms, a multicausal genesis can be assumed, involving both direct viral effects and indirect effects, particularly from the imposed lockdowns with devastating consequences for the elderly: decreased physical activity, altered diet, sarcopenia, fatigue, social isolation, neurological problems, inflammation, and cardiovascular morbidity are among the possible mediators. Since the COVID-19 pandemic is leading to an increase in frailty in the elderly, there is an urgent need to raise awareness of this still little-known problem of potentially great public health importance and to find appropriate prevention and treatment measures.

Risk factors and outcomes of delirium in hospitalized older adults with COVID-19: A systematic review and meta-analysis

Background

Older adults with COVID-19 are more likely to present with atypical symptoms, notably delirium. The main objective of this meta-analysis is to identify risk factors for delirium and outcomes of delirium in hospitalized older adults (65 years or above) with COVID-19.

Methods

Comprehensive literature search of Embase, CINAHIL, Medline and Web of Science was performed for published literature until 31st August 2021. Two independent researchers evaluated study eligibility and assessed study quality using the Newcastle Ottawa Scale (NOS) for cohort studies and Joanna Briggs Institute (JBI) critical appraisal tools for case series. The association of various predisposing factors with delirium in this cohort was reported as odds ratio (OR) and its 95% confidence interval (CI).

Results

A total of 31 studies from 11 countries were included in this review. Most of the included studies investigated patients from non-ICU settings (n = 24; 77.4%). Frailty (OR 3.52, 95% CI: 1.96-6.31, p<0.0001, I²=71.63%), cognitive impairment including dementia (OR 6.17, 95% CI: 2.92-13.07, p<0.00001, I²=88.63%) and being nursing home residents (OR 1.72, 95% CI: 1.31-2.24, p<0.0001, I²=0) were significantly associated with increased likelihood of developing delirium in older adults with COVID-19. The presence of delirium also significantly increases mortality risk in hospitalized older adults with COVID-19 (OR 2.51, 95% CI: 1.51-4.17, p<0.0001, I²=89.3%).

Conclusion

Our review identifies key factors associated with increased risk of developing delirium in hospitalized older adults with COVID-19. Identification of patients at risk of delirium and attention to these factors early during admission may improve outcomes for this vulnerable cohort.

The effectiveness of a group-based Otago exercise program on physical function, frailty and health status in older nursing home residents: A systematic review and meta-analysis

OBJECTIVES

To explore the effects of a group-based Otago exercise program (OEP) on physical function (mobility, balance, lower limb strength), frailty and health status in older nursing home residents to determine the optimal scheme and format.

METHODS

This systematic review and meta-analysis was conducted to estimate group-based OEP effects. Subgroup analysis was performed to identify the influences of the participant and intervention characteristics on the effects.

RESULTS

Twelve studies met the eligibility criteria and were included in this meta-analysis, and the overall quality was relatively high. The results showed that the group-based OEP significantly improved physical function, including mobility [SMD=-0.64, 95% CI (-0.83,-0.45), Z=6.55, p<0.001], balance [MD=4.72, 95% CI (3.54, 5.90), Z=7.84, p<0.001], lower limb strength [SMD=-1.09, 95% CI (-1.40, -0.79), Z=7.01, p<0.001]; frailty [SMD=-0.73, 95% CI (-1.01, -0.45), Z=5.13, p<0.001] and health status [SMD=0.47, 95% CI (0.20, 0.74), Z=3.44, p=0.0006]. Subgroup analysis revealed that 30-minute sessions were more beneficial for improving balance than >30-minute sessions (p=0.0004). The training was coordinated with physiotherapists, who were more skilled at improving mobility than providing health training education (p=0.04).

CONCLUSIONS

Group-based OEP is helpful for improving physical function, frailty and health status in older nursing home residents. Specifically, 30-minute sessions and coordinating with physiotherapists may be the most appropriate and effective options.

Institutional Residence Protects Against Cognitive Frailty: A Cross-Sectional Study

Based on the complex aging background, more and more older people have to live in an institution in later life in China. The prevalence of cognitive frailty (CF) is more higher in institutions than in communities. Rarely studies were conducted on the relationship between institutional residence and CF. Hence, this study were performed to determine the relationship between institutional residence (living in a nursing home) and CF in older adults. A total of 1004 older community residents and 111 older nursing home residents over 50 years of age from Hefei, Anhui Province, China were recruited. CF included physical frailty (PF) and mild cognitive impairment (MCI). PF was assessed using the Chinese version of the Fried frailty scale, MCI was assessed using the Montreal Cognitive Assessment, and the common associated factors including sedentary behavior, exercise, intellectual activity, comorbidity, medication, chronic pain, sleep disorders, nutritional status and loneliness were analyzed using regression logistic models. Multivariate regression logistic analysis showed that exercise (P = .019, odds ratio [OR] = 0.494, 95% confidence interval [CI]: 0.274-0.891), intellectual activity (P = .019, OR = 0.595, 95% CI: 0.380-0.932), medication use (P = .003, OR = 2.388, 95% CI: 1.339-4.258), chronic pain (P = .003, OR = 1.580, 95% CI: 1.013-2.465) and loneliness (P = .000, OR = 2.991, 95% CI: 1.728-5.175) were significantly associated with CF in community residents; however, only sedentary behavior (P = .013, OR = 3.851, 95% CI: 1.328-11.170) was significantly associated with CF in nursing home residents. Our findings suggest that nursing homes can effectively address many common risk factors for CF, including lack of exercise and intellectual activity, medication use, chronic pain, and loneliness, better than the community setting. Thus, residing in a nursing home is conducive to the intervention of CF.

Health profiles of older nursing home residents by suicidal ideation: A latent class analysis

OBJECTIVES

Identify the health profiles of older nursing home residents with and without at-admission self-reported suicidal ideation (SI) and examine the association between the identified profiles and self-reported SI at 90 days.

METHODS

Using the Minimum Data Set 3.0 and the ninth Patient Health Questionnaire-9 (PHQ-9) item, we identified 15,277 older residents with and 562,184 without self-reported SI at nursing home admission. Latent class analysis, using frailty, cognitive impairment, palliative care index, pain, and remaining PHQ-9 items as indicators, identified health profiles by at-admission SI and the BCH method estimated their association with SI at 90 days.

RESULTS

Profiles identified for residents without at-admission SI were: (1) frail and depressedNoSI (prevalence: 33.9%); (2) frail and severe cognitive impairmentNoSI (38.1%); (3) pre-frailNoSI (28.0%). Residents in the frail and depressedNoSI group had greater odds [adjusted OR: 2.80; 95% Confidence Interval: 2.60-3.00] while those in the frail and severe cognitive impairmentNoSI group had lower odds [aOR: 0.79; 95% CI: 0.71-0.86] of 90-day SI than those in the pre-frailNoSI group. Profiles identified for residents with at-admission SI were: (1) frail and all depressive symptomsSI (22.8%); (2) frail and some depressive symptomsSI (32.2%); (3) frail and severe cognitive impairmentSI (22.9%); (4) pre-frailSI (22.0%). Compared to those in the pre-frailSI group, residents in the frail and all depressive symptomsSI group had greater odds of continuing reporting SI at 90 days [aOR: 1.22; 95% CI:1.09-1.35].

CONCLUSIONS

Findings indicated unique health profiles of nursing home residents at higher risk of new onset of or continued SI.

Frailty and cognitive impairment in Parkinson’s disease: a systematic review

BACKGROUND

Frailty can lead to increased vulnerability in older people and patients with Parkinson's disease (pwPD) and worsen their health conditions. These patients can also develop cognitive function impairment. The objective is to analyze whether there is a relationship between frailty and cognitive impairment in pwPD, and to find out which instruments to use for its evaluation.

METHODS

Publications were searched in PubMed, Medline, Web of Science, Cinalh, Cochrane Library, Embase, Phycinfo, and Scopus. The results were measured with the instruments that are used to assess frailty and cognitive impairment, and analyze their relationship.

RESULTS

Two hundred seventy-one articles were identified, of which 12 met the inclusion criteria. All studies assessed frailty and cognitive function in pwPD. Five studies analyzed the relationship between frailty and cognitive impairment. The most used instruments were the Fried scale followed by the Clinical Frailty Scale (CFS) for frailty. Cognitive impairment was mostly evaluated with the Mini-Mental State Examination and the Montreal Cognitive Assessment. The prevalence data ranged from 20.2 to 51.5% with the Fried scale and from 35.6 to 83.9% with the CFS. Cognitive impairment was present in 15 to 45.2% of the pwPD.

CONCLUSION

Analysis of the included studies shows a relationship between frailty and cognitive impairment in pwPD. There was significant variability in the application of the scales used, which influences the prevalence data. More observational and experimental studies are needed to provide more evidence on this association and to determine which is the optimal tool to identify frailty in pwPD using multidimensional scales.

Global Research on Cognitive Frailty: A Bibliometric and Visual Analysis of Papers Published during 2013–2021

This study analyzed the current status, hotspots, and emerging trends of global research on cognitive frailty, in order to provide new research ideas for researchers. Articles and reviews related to cognitive frailty, published from 2013 to 2021, were retrieved from the Web of Science Core Collection (WoSCC) database on 26 November 2021. CiteSpace 5.8.R3 was employed for data analyses. A total of 2077 publications were included. There has been a rapid growth of publications on cognitive frailty research since 2016. The United States, Italy, England, and Australia have been the leading research centers of cognitive frailty; however, China has also recently focused on this topic. The National Center for Geriatrics and Gerontology, and Shimada H. were found to be the most prolific institution and author, respectively. Co-citation analysis identified 16 clusters, of which the largest was cognitive frailty. The keywords which occurred most frequently were “older adult”, followed by “cognitive impairment”, “frailty”, “risk”, “dementia”, “prevalence”, “mortality”, “health”, and “Alzheimer’s disease”. Burst keyword detection revealed a rising interest in cognitive frailty models. By analyzing these publications from recent years, this study provides a comprehensive analysis of cognitive frailty research.

Trajectories of physical frailty and cognitive impairment in older adults in United States nursing homes

Background

U.S. nursing homes provide long-term care to over 1.2 million older adults, 60% of whom were physically frail and 68% had moderate or severe cognitive impairment. Limited research has examined the longitudinal experience of these two conditions in older nursing home residents.

Methods

This national longitudinal study included newly-admitted non-skilled nursing care older residents who had Minimum Data Set (MDS) 3.0 (2014–16) assessments at admission, 3 months, and 6 months (n = 266,001). Physical frailty was measured by FRAIL-NH and cognitive impairment by the Brief Interview for Mental Status. Separate sets of group-based trajectory models were fitted to identify the trajectories of physical frailty and trajectories of cognitive impairment, and to estimate the association between older residents’ characteristics at admission with each set of trajectories. A dual trajectory model was used to quantify the association between the physical frailty trajectories and cognitive impairment trajectories.

Results

Over the course of the first six months post-admission, five physical frailty trajectories [“Consistently Frail” (prevalence: 53.0%), “Consistently Pre-frail” (29.0%), “Worsening Frailty” (7.6%), “Improving Frailty” (5.5%), and “Consistently Robust” (4.8%)] and three cognitive impairment trajectories [“Consistently Severe Cognitive Impairment” (35.5%), “Consistently Moderate Cognitive Impairment” (31.8%), “Consistently Intact/Mild Cognitive Impairment” (32.7%)] were identified. One in five older residents simultaneously followed the trajectories of “Consistently Frail” and “Consistently Severe Cognitive Impairment”. Characteristics associated with higher odds of the “Improving Frailty”, “Worsening Frailty”, “Consistently Pre-frail” and “Consistently Frail” trajectories included greater at-admission cognitive impairment, age ≥ 85 years, admitted from acute hospitals, cardiovascular/metabolic diagnoses, neurological diagnoses, hip or other fractures, and presence of pain. Characteristics associated with higher odds of the “Consistently Moderate Cognitive Impairment” and “Consistently Severe Cognitive Impairment” included worse at-admission physical frailty, neurological diagnoses, hip fracture, and receipt of antipsychotics.

Conclusions

Findings provided information regarding the trajectories of physical frailty, the trajectories of cognitive impairment, the association between the two sets of trajectories, and their association with residents’ characteristics in older adults’ first six months post-admission to U.S. nursing homes. Understanding the trajectory that the residents would most likely follow may provide information to develop a comprehensive care approach tailored to their specific healthcare goals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03012-8.

Cognitive Impairment and Cirrhosis in Older Patients: A Systematic Review

Prevalence of cirrhosis and hepatic encephalopathy (HE) in older patients receiving care in long-term care settings is unknown. This systematic review aimed to identify potential factors associated with HE and cognitive impairment in older patients with cirrhosis. A PubMed search of English-language articles published between January 1, 2000, and November 3, 2021, was conducted to identify studies in adults with cirrhosis relevant to cognitive impairment and/or HE (e.g., fall, frailty, and sarcopenia). Of 2,879 English-language publications, 24 were included. In patients with cirrhosis, falls were increased in the presence of HE and were associated with increased injury risk. Frailty was associated with HE development and cognitive impairment in patients with cirrhosis. Further, cognitive impairment and frailty were predictive of HE-related hospitalizations. Sarcopenia increased the risk of developing HE. Furthermore, specific medications increased the risk of developing HE. Risk reduction and management of patients with HE are critical to prevent negative outcomes.

Physical frailty and cognitive impairment in older nursing home residents: a latent class analysis

BACKGROUND

Little is known about the heterogeneous clinical profile of physical frailty and its association with cognitive impairment in older U.S. nursing home (NH) residents.

METHODS

Minimum Data Set 3.0 at admission was used to identify older adults newly-admitted to nursing homes with life expectancy ≥6 months and length of stay ≥100 days (n = 871,801). Latent class analysis was used to identify physical frailty subgroups, using FRAIL-NH items as indicators. The association between the identified physical frailty subgroups and cognitive impairment (measured by Brief Interview for Mental Status/Cognitive Performance Scale: none/mild; moderate; severe), adjusting for demographic and clinical characteristics, was estimated by multinomial logistic regression and presented in adjusted odds ratios (aOR) and 95% confidence intervals (CIs).

RESULTS

In older nursing home residents at admission, three physical frailty subgroups were identified: "mild physical frailty" (prevalence: 7.6%), "moderate physical frailty" (44.5%) and "severe physical frailty" (47.9%). Those in "moderate physical frailty" or "severe physical frailty" had high probabilities of needing assistance in transferring between locations and inability to walk in a room. Residents in "severe physical frailty" also had greater probability of bowel incontinence. Compared to those with none/mild cognitive impairment, older residents with moderate or severe impairment had slightly higher odds of belonging to "moderate physical frailty" [aOR (95%CI)moderate cognitive impairment: 1.01 (0.99-1.03); aOR (95%CI)severe cognitive impairment: 1.03 (1.01-1.05)] and much higher odds to the "severe physical frailty" subgroup [aOR (95%CI)moderate cognitive impairment: 2.41 (2.35-2.47); aOR (95%CI)severe cognitive impairment: 5.74 (5.58-5.90)].

CONCLUSIONS

Findings indicate the heterogeneous presentations of physical frailty in older nursing home residents and additional evidence on the interrelationship between physical frailty and cognitive impairment.

The FRAIL-NH Scale: Systematic Review of the Use, Validity and Adaptations for Frailty Screening in Nursing Homes

OBJECTIVES

To investigate frailty prevalence, cross-sectional associations, predictive validity, concurrent validity, and cross-cultural adaptations of the FRAIL-NH scale.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Frail residents living in nursing homes.

METHODS

MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched from January 2015 to June 2021 for primary studies that used the FRAIL-NH scale, irrespective of study designs and publication language.

RESULTS

Overall, 40 studies conducted across 20 countries utilized the FRAIL-NH scale; majority in Australia (n=14), followed by China (n=6), United States (n=3), and Spain (n=3). The scale has been translated and back-translated into Brazilian Portuguese, Chinese, and Japanese. Various cut-offs have been used, with ≥2 and ≥6 being the most common cut-offs for frail and most frail, respectively. When defined using these cut-offs, frailty prevalence varied from 15.1-79.5% (frail) to 28.5-75.0% (most frail). FRAIL-NH predicted falls (n=2), hospitalization or length of stay (n=4), functional or cognitive decline (n=4), and mortality (n=9) over a median follow-up of 12 months. FRAIL-NH has been compared to 16 other scales, and was correlated with Fried's phenotype (FP), Frailty Index (FI), and FI-Lab. Four studies reported fair-to-moderate agreements between FRAIL-NH and FI, FP, and the Comprehensive Geriatric Assessment. Ten studies assessed the sensitivity and specificity of different FRAIL-NH cut-offs, with ≥8 having the highest sensitivity (94.1%) and specificity (82.8%) for classifying residents as frail based on FI, while two studies reported an optimal cut-off of ≥2 based on FI and FP, respectively.

CONCLUSION

In seven years, the FRAIL-NH scale has been applied in 20 countries and adapted into three languages. Despite being applied with a range of cut-offs, FRAIL-NH was associated with higher care needs and demonstrated good agreement with other well-established but more complex scales. FRAIL-NH was predictive of adverse outcomes across different settings, highlighting its value in guiding care for frail residents in nursing homes.