Predictability of frailty index and its components on mortality in older adults in China

Disparities in overall survival by varying duration of disability in activities of daily living in older people: A population-based cohort from Chinese Longitudinal Healthy Longevity Survey (CLHLS)

OBJECTIVES

To investigate the association between duration of disability in activity of daily living (ADL) and overall survival in older individuals.

DESIGN

A prospective cohort study.

SETTING

Community-based data from Chinese Longitudinal Healthy Longevity Survey.

PARTICIPANTS

In total, 13,560 participants without ADL disability and 2772 participants with ADL disability at baseline were included.

MEASUREMENTS

ADL disability was assessed using Katz index scale, which included six essential ADLs: dressing, bathing, transferring, toileting, continence, and eating. Dependence of each item was scored on a scale of 1, the maximum total score was 6. At baseline, duration of ADL disability was defined as the maximum duration among the six items. The study outcome was overall survival. Accelerated failure time models were constructed to investigate the association between duration of ADL disability and overall survival. Subgroup analyses by sex, age, and multimorbidites, as well as sensitive analyses were conducted.

RESULTS

During 81,868.7 person-years follow-up, 11,092 deaths were recorded. Overall, ADL disability was associated with lower overall survival compared to non-ADL disability. With duration of ADL disability extending, the overall survival strikingly dropped in the first 12 months, reaching its lowest point with adjusted time ratio (TR) at 0.66 (95%CI: 0.61-0.72, p < 0.001), then moderately grew until the 60th month, finally stayed constant thereafter. Participants with ADL scores of 1-3 had higher survival compared to those with scores of 4-6, and both groups followed a similar trend of varied survival to the whole cohort. Moreover, subgroup analyses and sensitivity analyses showed the robustness of these findings.

CONCLUSIONS

Our findings first address a golden time window for the older individuals with ADL disability. More attention should be given to them, especially in the first 12 months since diagnosis, to reduce mortality and extend the lifespan.

The role of frailty among the predictors of depression on informal caregivers of older adults: a mediation analysis

BACKGROUND

Providing care for older adults has been associated with the presence of depressive symptoms among their informal caregivers. Numerous caregivers and older adults' characteristics have been mentioned as predictors of caregivers' depression. However, studies dealing with the impact of older adults' frailty status on caregivers' depression are scarce. This study was conducted to clarify the precise relationship between caregivers' depression, caregivers' burden, caregivers' characteristics and patients' characteristics, including frailty, among the variables that may have an impact on caregivers' depression.

METHODS

In this cross-sectional study, patients and caregivers' characteristics were recorded for 311 patient-caregiver dyads, when the patient was admitted to the hospital. For the purpose of the study, a mediation analysis was used with patients and caregiver characteristics considered to be predictors, subjective caregivers' burden as the mediator, and caregivers' depression as the outcome variable.

RESULTS

Only patients' frailty and caregivers' subjective burden had a direct effect on caregivers' depression. Moreover, caregivers' gender, patients' frailty status and comorbidity, duration of caregiving, and the relationship with the patient, had an indirect effect through caregivers' burden that acted as mediator. Regarding total effects, caregivers burden followed by patients' frailty status had the greater impact on caregivers' depression.

CONCLUSIONS

By organising interventions to reduce caregivers' depression, patients' frailty status could be among the targets of those interventions considering that frailty might be delayed or reversed.

Impact of combinations of subscale declines in higher-level functional capacity on 8-year all-cause mortality among community-dwelling older Japanese adults

BACKGROUND

The frequency of combined declines in domains of multi-faceted frailty and their impact on adverse health outcomes have not been adequately investigated. We aimed to examine the association between combined subscale declines in higher-level functional capacity and 8-year all-cause mortality among community-dwelling older Japanese individuals and the impact of multi-faceted frailty on mortality.

MATERIALS AND METHODS

We administered a questionnaire to 7015 community-dwelling older adults aged 65-85 years. The higher-level functional capacity of the 3381 respondents was assessed using the Tokyo Metropolitan Institute of Gerontology Index of Competence. Subscale decline was defined as (1) none, (2) only social role (SR), (3) only intellectual activity (IA), (4) SR and IA, (5) only instrumental activities of daily living (IADL), (6) IADL and SR, (7) IADL and IA, and (8) all. Associations between combined subscale declines and mortality were examined using adjusted Cox proportional hazards models. Follow-up was conducted from October 1, 2012, to death or November 1, 2020.

RESULTS

The mortality rate was 16.7/1000 person-years. Moreover, 44% of respondents had declined SR, and half of them had multiple declines. Compared with no decline, SR (adjusted hazard ratio [HR]: 1.49, 95% confidence interval [CI]: 1.14-1.93), SR and IA (HR: 1.59, 95% CI: 1.16-2.17), IADL and SR (HR: 1.97, 95% CI: 1.31-2.99), and all-domain (HR: 2.72, 95% CI: 1.98-3.74) declines were significantly associated with higher mortality risks.

CONCLUSIONS

Overlapping SR and IADL declines increased mortality risk, suggesting the importance of measuring social frailty and overlapping physical and social frailty.

Longitudinal Association Between Perceived Availability of Home- and Community-Based Services and All-Cause Mortality Among Chinese Older Adults: A National Cohort Study

Home- and community-based services (HCBS) may contribute to lowering mortality and enhancing quality of life among older adults. Limited research, however, has examined this relationship in the Chinese context. This study explored the longitudinal association between perceived availability of HCBS and all-cause mortality among Chinese older adults. This cohort study included 8,102 individuals aged 65 years and older from the 2011, 2014, and 2018 waves of the Chinese Longitudinal Healthy Longevity Survey. HCBS included daily life assistance, medical care services, emotional support and social services, and reconciliation and legal aid services. The association between perceived availability of HCBS and all-cause mortality was investigated using Cox proportional hazards models. Emotional support and social services were negatively associated with all-cause mortality (HR = 0.86, 95% CI: 0.78 ~ 0.95, P = .004). Daily life assistance, medical care services, and reconciliation and legal aid services were not significantly associated with all-cause mortality. Providing community-level emotional support and social services may reduce the risk of death. Focusing on the mental health and social well-being of older adults is just as important as caring for their physical health.

Frailty and risk of adverse outcomes among community-dwelling older adults in China: a comparison of four different frailty scales

Background

Data on which frailty scales are most suitable for estimating risk in Chinese community populations remain limited. Herein we examined and compared four commonly used frailty scales in predicting adverse outcomes in a large population-based cohort of Chinese older adults.

Methods

A total of 5402 subjects (mean age 66.3 ± 9.6 years, 46.6% male) from the WHO Study on global AGEing and adult health (SAGE) in Shanghai were studied. Frailty was measured using a 35-item frailty index (FI), the frailty phenotype (FP), FRAIL, and Tilburg Frailty Indicator (TFI). Multivariate logistic regression models were performed to evaluate the independent association between frailty and outcomes including 4-year disability, hospitalization, and 4- and 7-year all-cause mortality. The accuracy for predicting these outcomes was determined by evaluating the area under the curve (AUC). The prevalence of frailty, sensitivity, and specificity were calculated using our proposed cut-off points and other different values.

Results

Prevalence of frailty ranged from 4.2% (FRAIL) to 16.9% (FI). FI, FRAIL and TFI were comparably associated with 4-year hospitalization, and 4- and 7-year mortality (adjusted odds ratios [aORs] 1.44-1.69, 1.91-2.22 and 1.85-2.88, respectively). FRAIL conferred the greatest risk of 4-year disability, followed by FI and TFI (aOR 5.55, 3.50, and 1.91, respectively). FP only independently predicted 4- and 7-year mortality (aOR 1.57 and 2.21, respectively). AUC comparisons showed that FI, followed by TFI and FRAIL, exhibited acceptable predictive accuracy for 4-year disability, 4- and 7-year mortality (AUCs 0.76-0.78, 0.71-0.71, 0.65-0.72, respectively), whereas all scales poorly predicted 4-year hospitalization (AUCs 0.53-0.57). For each scale, while specificity estimates (85.3-97.3%) were high and similar across all outcomes, their sensitivity estimates (6.3-56.8%) were not sufficient yet. Prevalence of frailty, sensitivity, and specificity varied considerably when different cut-off points were used.

Conclusion

Frailty defined using any of the four scales was associated with an increased risk of adverse outcomes. Although FI, FRAIL and TFI exhibited fair-to-moderate predictive accuracy and high specificity estimates, their sensitivity estimates were not sufficient yet. Overall, FI performed best in estimating risk, while TFI and FRAIL were additionally useful, the latter perhaps being more applicable to Chinese community-dwelling older adults.

Development and Validation of the Disability Index Among Older Adults

BACKGROUND

With the rapid population aging, the challenge to provide care for disabled older adults is becoming bigger. This study aims to develop the Disability Index (DI) to assess disability to indicate care needs, and we evaluated the reliability and validity of the DI among older adults aged 65-105.

METHODS

A total of 12 559 older adults (54.0% women; mean age = 84.3; SD = 11.2) from 22 provinces in China were investigated in 2017-2018. We developed the 21-item DI covering 4 subdomains, including Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), physical performance, and cognitive function. Cronbach's alpha was used to determine internal consistency. The convergent and divergent validity were assessed by Spearman rank order correlation coefficients and Pearson correlation coefficients. The known-group validity was assessed by Mann-Whitney U tests. The concurrent validity was assessed by the area under the receiver operating characteristic curve (AUC).

RESULTS

In the total sample, the internal consistency of the full DI and its subdomains were satisfactory with Cronbach's alpha ≥0.70; the convergent and divergent validity of the 4 subdomains were supported by all the alternative measures; the known-group validity of the full DI and its subdomains were supported by clear discriminative ability; and the concurrent validity of the full DI was supported with all the AUCs ≥0.70. The reliability and validity of the full DI and its subdomains were additionally supported by age subgroups and sex subgroups.

CONCLUSIONS

The DI is a reliable and valid instrument to assess disability status among older adults.

Effects of functional limitations and activities of daily living on the mortality of the older people: A cohort study in China

Introduction

Prevalence of functional limitations (FLs) and disabled activities of daily living (ADL) cause heavy burdens to the health of the older people. Stratified by gender, this study aimed to explore the effects of FL and ADL on the mortality of the older people in China, and the mechanism was then discussed.

Methods

We used survey data of a prospective 10-year cohort (2008-2018), from the China Longitudinal Healthy Longevity Survey (CLHLS). The primary outcome was all-cause mortality, and Independent variables included FL, basic ADL (BADL), and instrumental ADL (IADL). Covariates involved socio-demographic characteristics, health-related behaviors, and health status of the participants in the CLHLS project.

Results

There were 967 (19.20%) male and 2,235 (32.36%) female older people performed functional limitations, and their survival time was 60.98 (SE = 0.66) and 55.19 (SE = 0.55) months, respectively. Old adults with FL had significantly poorer survival than the ones without (Log-rank test, P < 0.001). Weibull regression suggested that FL (P < 0.001), abnormal BADL (P < 0.001) and IADL (P < 0.001) were negatively associated with the survival of the older people. Further analysis showed that BADL and IADL performed significantly mediating roles in the relation of FL and survival time in old adults; additionally, for female older people, BADL also exhibited a significant moderating role in the effect of FL on survival.

Conclusions

Prevalence of FL was serious among the older people in China, especially for the women. Disabilities of BADL and IADL and FL were negatively associated with the survival time of the older people in China. Regarding the effect of FL on survival, BADL and IADL performed significantly mediating roles, and the moderating role of BADL existed only for the female. These suggested evidence to implement strategies to maintain health in the older people.

The path to healthy ageing in China: a Peking University-Lancet Commission

Around the world, populations are ageing at a faster pace than in the past and this demographic transition will have impacts on all aspects of societies. In May 2020, the UN General Assembly declared 2021–2030 the Decade of Healthy Ageing, highlighting the importance for policymakers across the world to focus policy on improving the lives of older people, both today and in the future. While rapid population ageing poses challenges, China’s rapid economic growth over the last forty years has created space for policy to assist older persons and families in their efforts to improve health and well-being at older ages. As China is home to 1/5 of the world’s older people, China is often held up as an example for other middle-income countries. This Commission Report aims to help readers to understand the process of healthy ageing in China as a means of drawing lessons from the China experience. In addition, with the purpose of informing the ongoing policy dialogue within China, the Commission Report highlights the policy challenges on the horizon and draws lessons from international experience.

The identification and prediction of frailty based on Bayesian network analysis in a community-dwelling older population

Background

We have witnessed frailty, which characterized by a decline in physiological reserves, become a major public health issue in older adults. Understanding the influential factors associated with frailty may help prevent or if possible reverse frailty. The present study aimed to investigate factors associated with frailty status and frailty transition in a community-dwelling older population.

Methods

A prospective cohort study on community-dwelling subjects aged ≥ 60 years was conducted, which was registered beforehand (ChiCTR 2,000,032,949). Participants who had completed two visits during 2020–2021 were included. Frailty status was evaluated using the Fried frailty phenotype. The least absolute shrinkage and selection operator (LASSO) regression was applied for variable selection. Bayesian network analysis with the max-min hill-climbing (MMHC) algorithm was used to identify factors related to frailty status and frailty transition.

Results

Of 1,981 subjects at baseline, 1,040 (52.5%) and 165 (8.33%) were classified as prefrailty and frailty. After one year, improved, stable, and worsening frailty status was observed in 460 (35.6%), 526 (40.7%), and 306 (23.7%) subjects, respectively. Based on the variables screened by LASSO regression, the Bayesian network structure suggested that age, nutritional status, instrumental activities of daily living (IADL), balance capacity, and social support were directly related to frailty status. The probability of developing frailty is 14.4% in an individual aged ≥ 71 years, which increases to 20.2% and 53.2% if the individual has balance impairment alone, or combined with IADL disability and malnutrition. At a longitudinal level, ADL/IADL decline was a direct predictor of worsening in frailty state, which further increased the risk of hospitalization. Low high-density lipoprotein cholesterol (HDL-C) and diastolic blood pressure (DBP) levels were related to malnutrition, and further had impacts on ADL/IADL decline, and ultimately led to the worsening of the frailty state. Knowing the status of any one or more of these factors can be used to infer the risk of frailty based on conditional probabilities.

Conclusion

Older age, malnutrition, IADL disability, and balance impairment are important factors for identifying frailty. Malnutrition and ADL/IADL decline further predict worsening of the frailty state.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03520-7.

The Impact of Frailty on Traumatic Brain Injury Outcomes: An Analysis of 691 821 Nationwide Cases

BACKGROUND

Frailty, a decline in physiological reserve, prognosticates poorer outcomes for several neurosurgical conditions. However, the impact of frailty on traumatic brain injury outcomes is not well characterized.

OBJECTIVE

To analyze the association between frailty and traumatic intracranial hemorrhage (tICH) outcomes in a nationwide cohort.

METHODS

We identified all adult admissions for tICH in the National Trauma Data Bank from 2007 to 2017. Frailty was quantified using the validated modified 5-item Frailty Index (mFI-5) metric (range = 0-5), with mFI-5 ≥2 denoting frailty. Analyzed outcomes included in-hospital mortality, favorable discharge disposition, complications, ventilator days, and intensive care unit (ICU) and total length of stay (LOS). Multivariable regression assessed the association between mFI-5 and outcomes, adjusting for patient demographics, hospital characteristics, injury severity, and neurosurgical intervention.

RESULTS

A total of 691 821 tICH admissions were analyzed. The average age was 57.6 years. 18.0% of patients were frail (mFI-5 ≥ 2). Between 2007 and 2017, the prevalence of frailty grew from 7.9% to 21.7%. Frailty was associated with increased odds of mortality (odds ratio [OR] = 1.36, P < .001) and decreased odds of favorable discharge disposition (OR = 0.72, P < .001). Frail patients exhibited an elevated rate of complications (OR = 1.06, P < .001), including unplanned return to the ICU (OR = 1.55, P < .001) and operating room (OR = 1.17, P = .003). Finally, frail patients experienced increased ventilator days (+12%, P < .001), ICU LOS (+11%, P < .001), and total LOS (+13%, P < .001). All associations with death and disposition remained significant after stratification for age, trauma severity, and neurosurgical intervention.

CONCLUSION

For patients with tICH, frailty predicted higher mortality and morbidity, independent of age or injury severity.

Functional dentition is a modifier of the association between vitamin D and the frailty index among Chinese older adults: a population-based longitudinal study

Backgrounds

Although vitamin D and dentition status are each associated with frailty, their combined effects on frailty have not been studied. This study aimed to evaluate the combined effects of vitamin D and dentition status on frailty in old Chinese adults.

Methods

Baseline data were obtained from the 2011–2012 wave of the Chinese Longitudinal Healthy Longevity Survey. A total of 1074 participants ≥65 years who were non-frail or prefrail at baseline were included; follow-up was conducted in the 2014 wave. Frailty was assessed by a 40-item frailty index (FI) and classified into frail (FI > 0.21), prefrail (FI: 0.1–0.21), and non-frail (FI ≤0.1). Vitamin D was assessed by 25-Hydroxyvitamin D (25(OH)D) and categorized into quartiles and dichotomies (normal: ≥50 nmol/L vs. low: < 50 nmol/L). The presence of ≥20 natural teeth was defined as functional dentition, otherwise as non-functional dentition. We used bivariate logistic regression and restricted cubic splines to examine the association between vitamin D, dentition status, and frailty. We created a multiplicative interaction between vitamin D and dentition status to test for their combined effect.

Results

A total of 205 (19.1%) incident frailty were identified during the 3-year follow-up. Participants with the lowest quartile of plasma 25(OH) D were more likely to be frail (odds ratio [OR] 2.45, 95% confidence interval [CI]: 1.38 to 4.35) than those in the highest quartile. Older adults with the lowest quartile of 25(OH) D and non-functional dentition had the highest odds of frailty (OR = 3.67, 95% CI: 1.02 to 13.12). We also observed that a lower vitamin D level was associated with an increased risk of frailty with a threshold of 40.37 nmol/L using restricted cubic spline models. However, vitamin D levels were not significantly associated with frailty among participants with functional dentition.

Conclusions

Low vitamin D levels were associated with an increased risk of frailty in older adults. Functional dentition modified the association of vitamin D with frailty.

Associations of Serum Albumin With Disability in Activities of Daily Living, Mobility and Objective Physical Functioning Regardless of Vitamin D: Cross-Sectional Findings From the Chinese Longitudinal Healthy Longevity Survey

Objective

To examine the associations of serum albumin, a nutrition indicator, with disability in activities of daily living (ADL), mobility, and objective physical functioning among Chinese older adults.

Materials and Methods

Cross-sectional data of 2233 older adults (≥65 years) who participated in the 2011/2012 main survey of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) and the 2012 biomarker sub-study was used. Serum albumin was measured by immunoturbidimetric assay. Physical functioning included subjectively (ADL and mobility) and objectively measured disability (standing up from a chair, picking up a book from the floor, and turning around 360°). Multivariable logistic regression models were performed.

Results

After adjusting for age and sex, compared with participants in the lowest quartile group of serum albumin, those in the highest quartile group had 45% lower odds of disability in ADL (odds ratio [OR]: 0.55; 95% confidence interval [CI]: 0.38, 0.80); 48% lower odds of disability in mobility (OR: 0.52; 95% CI: 0.38, 0.71); 46% lower odds of disability in standing up from a chair (OR: 0.54; 95% CI: 0.34, 0.85); and 37% lower odds of disability in picking up a book from the floor (OR: 0.63; 95% CI: 0.40, 0.97). We did not observe a statistically significant interaction effect between serum albumin and vitamin D on disability in physical functioning.

Conclusion

Serum albumin level was associated with physical functioning among Chinese older adults, regardless of vitamin D level. The findings indicate that appropriate management of poor nutritional status, in particular low serum albumin levels, may contribute to maintaining physical functioning in older adults.

Frailty Status Among the Elderly of Different Genders and the Death Risk: A Follow-Up Study

Background: Frailty in the elderly population is currently a frontier and focus in the field of health and aging. The goal of this study was to explore the frailty status among the elderly of different genders and its influence on the risk of death during 11 years.

Methods: Frailty index (FI) was used to evaluate the frailty status in the elderly based on the baseline data conducted in 2009; and death as outcome variables collected in 2020 were analyzed. The difference of the frailty level and mortality of different genders was compared. Cox regression and Kaplan–Meier curves were applied to evaluate the influence on the risk of death and the 11-year survival of the elderly at different level of frailty, respectively.

Results: Totally, 1,246 elderly people were recruited. The mortality in men (43.7%, 227/519) was statistically higher than that in women (34.3%, 249/727) (x² = 11.546, P = 0.001). Deficits accumulated exponentially with age, and at all ages, women accumulated more deficits than do men on average (B = 0.030 vs. 0.028, t = 4.137, P = 0.023). For any given level of frailty, the mortality rate is higher in men than in women, and the difference in mortality between genders reached the peak when FI value was 0.26. Cox regression analysis showed that FI value had a greater impact on the risk of death in older men (HR = 1.171, 95%CI: 1.139~1.249)than that in older women (HR = 1.119, 95%CI: 1.039~1.137). Survival analysis showed that the median 11-year survival time in women was longer than that in men (95.26 vs. 89.52 months, Log rank = 9.249, P = 0.002). Kaplan–Meier curves showed that the survival rate decreased with the increase of frailty, and at the same level of frailty, survival time in older women was longer than that in older men, except for severe frailty (FI ≥ 0.5).

Conclusion: The frailty status and its influence on mortality are different among the older people of different genders; therefore, specific interventions for frailty should be conducted in the elderly population of different genders, as well as of different degrees of frailty.

Age- and Gender-Specific Prevalence of Frailty and Its Outcomes in the Longevous Population: The Chinese Longitudinal Healthy Longevity Study

Background: Frailty is an epidemic age-related syndrome addressing heavy burden to the healthcare system. Subject to the rarity, age-, and gender-specific prevalence of frailty and its prognosis among the longevous population remains under-investigated.

Methods: Based on the Chinese Longitudinal Healthy Longevity Study (CLHLS, 2008–2018), individuals aged ≥ 65 years having complete data of frailty were recruited. Modified Fried criteria (exhaustion, shrink, weakness, low mobility, and inactivity) were adopted to define pre-frailty (1–2 domains) and frailty (≥3 domains), respectively. The association between pre-frailty/frailty and adverse outcomes (frequent hospitalization, limited physical performance, cognitive decline, multimorbidity, and dependence) was analyzed using logistic regression models. The association between pre-frailty/frailty and mortality was analyzed using Cox proportional hazards models. Age- and gender-stratified analyses were performed.

Results: Totally, 13,859 participants aged 85.8 ± 11.1 years, including 2,056 centenarians, were recruited. The overall prevalence of pre-frailty and frailty were 54.1 and 26.3%, respectively. Only 5.0% of centenarians were non-frailty whereas 59.9% of the young-old (65–79 years) showed pre-frailty. Both pre-frailty and frailty were associated with the increased risk of multiple adverse outcomes, such as incident limited physical performance, cognitive decline and dependence, respectively (P < 0.05). Frail males were more vulnerable to the risk of mortality (hazard ratio [HR] = 2.3, 95% confidence interval [CI], 2.1–2.6) compared with frail females (HR = 1.9, 95%CI, 1.7–2.1). The strongest association between frailty and mortality was observed among the young-old (HR = 3.6, 95%CI, 2.8–4.5). Exhaustion was the most common domain among patients with pre-frailty (74.8%) or frailty (83.2%), followed by shrink (32.3%) in pre-frailty and low mobility (83.0%) in frailty. Inactivity among females aged 65–79 years showed the strongest association with the risk of mortality (HR = 3.50, 95%CI, 2.52–4.87).

Conclusion: A huge gap exists between longer life and healthy aging in China. According to the age- and gender-specific prevalence and prognosis of frailty, the strategy of frailty prevention and intervention should be further individualized.

Causal effects of physical activity and sedentary behaviour on health deficits accumulation in older adults

BACKGROUND

Increasing physical activity (PA) and reducing sedentary behaviour (SB) have been associated with healthy ageing, but their effects when adjusted for reverse causation and selection bias remain unclear.

METHODS

A deficits accumulation (DA) index based on the number and severity of 51 health deficits (0-100%) was calculated at baseline and three biannual follow-up visits, in a representative cohort of 3 228 community-dwelling older adults in Spain. Average differences in DA index by previous recreational PA, household PA, mentally-active SB and passive SB were estimated using marginal structural models with inverse probability of exposure and censoring weights.

RESULTS

Compared with participants with previous recreational PA of 10-19.9 metabolic equivalent hours/week (MET-hours/week), average differences in DA index (95% confidence intervals) were 0.19 (-1.09, 1.48), 0.69 (-0.23, 1.61), -0.66 (-1.34, 0.02), -0.87 (-1.59, -0.13) and -0.55 (-1.37, 0.28) for 0, 0.1-9.9, 20-29.9, 30-39.9 and ≥40 MET-hours/week, respectively (P for trend = 0.006). Household PA showed no effect on subsequent DA after adjusting for reverse causation. Women, but not men, who spent 7-14.9, 15-20.9 and ≥21 h/week on mentally active SB had DA decreases of 0.09 (-1.00, 1.19), 1.08 (-0.28, 2.45) and 2.17 (0.58, 3.75), respectively, compared with 1-6.9 h/week (P for trend = 0.005); whereas women who spent 3-3.9, 4-4.9 and ≥5 h/day on passive SB showed DA increases of 0.41 (-0.52, 1.35), 1.35 (0.13, 2.57) and 2.13 (0.78, 3.47), respectively, compared with 2-2.9 h/day (P for trend = 0.001).

CONCLUSIONS

The proposed methodology allows estimation of the causal effects of PA and SB on ageing, by simulating a random assignment in which all subjects have the same probability of exposure.

Validation of the revised 9-scale clinical frailty scale (CFS) in Greek language

BACKGROUND

Among many screening tools that have been developed to detect frailty in older adults, Clinical Frailty Scale (CFS) is a valid, reliable and easy-to-use tool that has been translated in several languages. The aim of this study was to develop a valid and reliable version of the CFS to the Greek language.

METHODS

A Greek version was obtained by translation (English to Greek) and back translation (Greek to English). The "known-group" construct validity of the CFS was determined by using test for trends. Criterion concurrent validity was assessed by evaluating the extent that CFS relates to Barthel Index, using Pearson's correlation coefficient. Both inter-rater and test-retest reliability were assessed using intraclass correlation coefficient.

RESULTS

Known groups comparison supports the construct validity of the CFS. The strong negative correlation between CFS and Barthel Index (rs = - 0,725, p ≤ 0.001), supports the criterion concurrent validity of the instrument. The intraclass correlation was good for both inter-rater (0.87, 95%CI: 0.82-0.90) and test-retest reliability (0.89: 95%CI: 0.85-0.92).

CONCLUSION

The Greek version of the CFS is a valid and reliable instrument for the identification of frailty in the Greek population.

A Comprehensive Overview of Activities of Daily Living in Existing Frailty Instruments: A Systematic Literature Search

BACKGROUND AND OBJECTIVES

The relationship between frailty and disability in activities of daily living (ADLs) can be seen in different ways, with disability being-to varying degrees-a characteristic, negative outcome, or predictor of frailty. This conflation of definitions is partly a result of the different frailty tools used in research. Aiming to provide a comprehensive overview, this systematic literature search analyzed (i) if, (ii) to what extent, and (iii) how ADLs are evaluated by frailty instruments.

RESEARCH DESIGN AND METHODS

A search was performed in PubMed, Web of Knowledge, and PsycINFO to identify all frailty instruments, followed by categorization of the ADL items into basic (b-), instrumental (i-), and advanced (a-) ADLs.

RESULTS

In total, 192 articles described 217 frailty instruments, from which 52.1% contained ADL items: 45.2% b-ADLs, 35.0% i-ADLs, and 10.1% a-ADLs. The most commonly included ADL items were bathing (b-ADLs); using transportation (i-ADLs); and semiprofessional work engagement in organized social life or leisure activities (a-ADLs). These instruments all had a multidomain origin (χ 2 = 122.4, p < .001).

DISCUSSION AND IMPLICATIONS

Because 52.1% of all instruments included ADL items, the concepts of frailty and disability appear to be highly entangled. This might lead to circular reasoning, serious concerns regarding contamination, and invalid research results.

Efficacy of Early (≤ 24 Hours), Late (25-72 Hours), and Delayed (>72 Hours) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades C and D Acute Traumatic Central Cord Syndrome Caused by Spinal Stenosis

The therapeutic significance of timing of decompression in acute traumatic central cord syndrome (ATCCS) caused by spinal stenosis remains unsettled. We retrospectively examined a homogenous cohort of patients with ATCCS and magnetic resonance imaging (MRI) evidence of post-treatment spinal cord decompression to determine whether timing of decompression played a significant role in American Spinal Injury Association (ASIA) motor score (AMS) 6 months following trauma. We used the t test, analysis of variance, Pearson correlation coefficient, and multiple regression for statistical analysis. During a 19-year period, 101 patients with ATCCS, admission ASIA Impairment Scale (AIS) grades C and D, and an admission AMS of ≤95 were surgically decompressed. Twenty-four of 101 patients had an AIS grade C injury. Eighty-two patients were males, the mean age of patients was 57.9 years, and 69 patients had had a fall. AMS at admission was 68.3 (standard deviation [SD] 23.4); upper extremities (UE) 28.6 (SD 14.7), and lower extremities (LE) 41.0 (SD 12.7). AMS at the latest follow-up was 93.1 (SD 12.8), UE 45.4 (SD 7.6), and LE 47.9 (SD 6.6). Mean number of stenotic segments was 2.8, mean canal compromise was 38.6% (SD 8.7%), and mean intramedullary lesion length (IMLL) was 23 mm (SD 11). Thirty-six of 101 patients had decompression within 24 h, 38 patients had decompression between 25 and 72 h, and 27 patients had decompression >72 h after injury. Demographics, etiology, AMS, AIS grade, morphometry, lesion length, surgical technique, steroid protocol, and follow-up AMS were not statistically different between groups treated at different times. We analyzed the effect size of timing of decompression categorically and in a continuous fashion. There was no significant effect of the timing of decompression on follow-up AMS. Only AMS at admission determined AMS at follow-up (coefficient = 0.31; 95% confidence interval [CI]:0.21; p = 0.001). We conclude that timing of decompression in ATCCS caused by spinal stenosis has little bearing on ultimate AMS at follow-up.

The activity of daily living (ADL) subgroups and health impairment among Chinese elderly: a latent profile analysis

Background

Disability in aged people became one of the major challenges in China due to the acceleration of population aging. Nevertheless, there were limited methods to appropriately discriminate the degree of combined basic activity of daily living (BADL) and instrumental activity of daily living (IADL). The present study explored an empirical typology of the activity of daily living (ADL) and its association with health status among the elderly in China.

Methods

Data throughout the Chinese Longitudinal Healthy Longevity Survey (CLHLS) was retrieved and Latent profile analysis (LPA) was conducted to identify the subgroups of ADL for included elderly subjects. Multinomial regression was performed to detect the effect of identified characteristics with ADL subgroups, and the restricted cubic spine was drawn to show the changes in the relationship between age-specific ADL disability and BMI.

Results

The overall participants (n=8108) were divided into three ADL classes by LPA - ‘no BADL limitation-no IADL limitation’ (Class one, n=6062, 75%), ‘no BADL limitation- IADL impairment’ (Class two, n=1526, 19%), and ‘BADL impairment- IADL impairment’ (Class three, n=520, 6%). Compared with the participants in Class one, the oldest-old, living without spouse, lacking of exercise, short in social activities, having experience of falls, having comorbidity of diabetes, heart disease, stroke, decreased cognitive function, depression symptom were highly associated with Class two and Class three. Additionally, malnutrition and asthma were associated with combined BADL/IADL impairment (Class three), while illiteracy was only associated with IADL impairment (Class two). Furthermore, a statistically significant U-shape association was detected between age and BADL/IADL disability (Class three vs. Class two) as well as BMI and BADL/IADL disability (Class three vs. Class one). The elderly aged 80–90 with IADL impairment were less likely to evolve into combined BADL/IADL impairment, and the elderly who were underweight or obese may have higher risk of combined BADL/IADL impairment.

Conclusion

A novel functional assessment was explored based on LPA, by which elderly people could be classified into three distinct classes of combined BADL/IADL. The predictors identified with particular IADL/BADL classes could draw early attention to the onset of functional disability and enlighten targeted interventions to address consequent problems of aged people.

Dynamic statistical model for predicting the risk of death among older Chinese people, using longitudinal repeated measures of the frailty index: a prospective cohort study

BACKGROUND

Frailty is a common characteristic of older people with the ageing process. We aimed to develop and validate a dynamic statistical prediction model to calculate the risk of death in people aged ≥65 years, using a longitudinal frailty index (FI).

METHODS

One training dataset and three validation datasets from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) were used in our study. The training dataset and validation datasets 1 to 3 included data from 9,748, 7,459, 9,093 and 6,368 individuals, respectively. We used 35 health deficits to construct the FI and a longitudinal FI based on repeated measurement of FI at every wave of the CLHLS. A joint model was used to build a dynamic prediction model considering both baseline covariates and the longitudinal FI. Areas under time-dependent receiver operating characteristic curves (AUCs) and calibration curves were employed to assess the predictive performance of the model.

RESULTS

A linear mixed-effects model used time, sex, residence (city, town, or rural), living alone, smoking and alcohol consumption to calculate a subject-specific longitudinal FI. The dynamic prediction model was built using the longitudinal FI, age, residence, sex and an FI-age interaction term. The AUCs ranged from 0.64 to 0.84, and both the AUCs and the calibration curves showed good predictive ability.

CONCLUSIONS

We developed a dynamic prediction model that was able to update predictions of the risk of death as updated measurements of FI became available. This model could be used to estimate the risk of death in individuals aged >65 years.

A self-reported Frailty Index predicts long-term mortality in hospitalized patients with cirrhosis

Background

Frailty is a syndrome that diminishes the potential for functional recovery in liver cirrhosis (LC). However, its utility is limited due to sole reliance on physical performance, especially in hospitalized patients. We investigate the predictive value of a modified self-reported Frailty Index in cirrhotics, and identify which health deficits play more important roles.

Methods

Consecutive LC patients were assessed by our frailty scale. Outcomes of interest were mortality for 90-day, 1-year and 2-year. Independent predictors were identified by multivariate Cox regression. Receiver operating characteristic curve (ROC) was performed to evaluate discriminative ability. We used a combination of stepwise selection, best subset selection, and Akaike information criteria (AIC) to identify pivotal frailty components.

Results

The study cohort consisted of 158 patients, in which 37 expired during follow-up. Compared with non-frail groups, the frail group had higher 1- and 2-year mortality. The area under ROC of the Child-Turcotte-Pugh classification (CTP) and Frailty Index were 0.66 and 0.68, while 0.72 for CTP + Frailty Index (P=0.034), respectively. The optimal predictors comprised instrumental activities of daily living (IADL) limitation, falls and loss of weight (AIC =170, C-statistic =0.67).

Conclusions

It is plausible for incorporating Frailty Index to improve prognostication in cirrhotics. IADL limitation, falls and loss of weight play more crucial roles on mortality determination.

The association between city-level air pollution and frailty among the elderly population in China

A growing body of research suggests that air pollution negatively affects specific health outcomes, but how long- and short-term exposure to air pollution are associated with frailty is unclear. Using longitudinal data from adults aged 65 and over from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) linked with air quality index data, we model a frailty score according to the city-level of air pollution exposure, adjusting for individual socio-demographic factors and city-level indicators. All models show increased frailty with higher exposure to air pollution in one year prior to the interview, when controlling for short-term fluctuations. Moreover, elderly people living in areas where air pollution increased over the follow-up had larger increases in frailty scores than those where air pollution was relatively constant. The results suggest that air pollution plays a role in healthy ageing.

Loneliness as a risk factor for frailty transition among older Chinese people

Background

Previous literature has reported that loneliness is a strong predictor of frailty risk. However, less is known about the role of loneliness in frailty transition types. This study aimed to examine whether and how loneliness are related to frailty transition among older Chinese people.

Methods

Our study used participants (aged ≥60 years) from 2008/2009, 2011/2012 and 2014 waves of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Loneliness was assessed by a single question asking how often the respondent feels lonely. The FRAIL Scale was created to measure physical frailty for our study, and frailty was also assessed by a broader definition of the frailty index. Frailty transition as an outcome variable has been designed as two types according to the measurement of frailty.

Results

Greater loneliness at baseline reduced the possibility of remaining in a robust or prefrail physical frailty state after 3 years (OR = 0.78, 95%CI: 0.68–0.91, p < 0.01). Greater loneliness was associated with an increased risk of worsening physical frailty over time: compared with those who had never felt lonely, the odds ratios for people who often felt lonely were 1.19 (95%CI: 1.01–1.41, p < 0.05) after 3 years and 1.34 (95%CI: 1.08–1.66, p < 0.01) after 6 years. The association between loneliness and change in the frailty index differed in the survey periods: loneliness at baseline was found to increase the possibility of participants remaining in frailty (seldom loneliness: OR = 1.78, 95%CI: 1.25–2.55, p < 0.01; often loneliness: OR = 1.74, 95%CI: 1.21–2.50, p < 0.01) after 6 years, but no significance was shown in the 3-year follow up. Additionally, loneliness at baselines was significantly associated with frailty transition at follow up among the male participants. However, a similar association was not observed among the female participants.

Conclusion

Older people with a high level of loneliness tend to be frail in the future, and greater loneliness is related to an increased risk of worsening frailty and remaining frail. Male elderly with a high level of loneliness were more likely to have a worse frailty transition than female elderly in China.

Predictors of loneliness incidence in Chinese older adults from a life course perspective: a national longitudinal study

Objectives: We aim to examine what factors are predictive of loneliness incidence from a life course perspective and whether predictors differ between women and men based on a nationally representative longitudinal dataset in China. Method: A total of 5,043 older adults aged 65 or above from the Chinese Longitudinal Healthy Longevity Survey who were not lonely in the 2008 wave were included in the analysis. Logistic regression models were applied to examine what factors in the 2008 wave predicted loneliness incidence in the 2011 wave. Analyses were also stratified by gender to examine gender differences.Results: Older ages and self-rated poor health increased the odds, whereas receiving one or more years of schooling, rural-urban migration, living with family members, having a white-collar job, having a good family economic status, being currently married, having a higher resilience and social support decreased the odds of loneliness incidence. We also found gender differences: socioeconomic factors were significant only for older men, whereas self-rated health, resilience, and social support were significant only for older women.Conclusion: This study offers insights into disentangling the complexity of factors associated with loneliness incidence in Chinese older adults from a life course perspective and from a gendered perspective.

Main Risk Factors Related to Activities of Daily Living in Non-Dialysis Patients with Chronic Kidney Disease Stage 3-5: A Case-Control Study

Introduction

Elderly people are at increased risk of falls, disability and death due to reduced functional reserve, decline in multiple systems functions, which affects their activities of daily living (ADL) and eventually develop into frailty. The ADL assessment is conducive to early detection to avoid further serious situations. Previous studies on patients’ activities of daily living with chronic kidney disease (CKD) are mainly focused on dialysis patients. Little information is available on non-dialysis patients.

Patients and Methods

A total of 303 elderly patients with CKD stage 3–5 who were admitted to our hospital were selected. ADL evaluation was performed on patients at admission, with Barthel index (BI) as the evaluation tool. They were divided into two groups based on BI (≥60 and <60). Demographic information, lifestyle and clinical profile were collected. The risk factors related to ADL were analyzed by univariate and multivariate models.

Results

The data of 303 patients enrolled in this study were analyzed. The average age of patients was 84.48± 7.14 years and 62.05% were male. There were 88 patients (29.04%) in BI <60 group and 215 patients (70.96%) in the BI ≥60 group. The average age of subjects in the two groups was 87.47 ± 5.85 years and 83.26± 7.28 years, respectively. On univariate analysis, ADL impairment was associated with many factors, such as age, body mass index, blood lipid, heart rate, smoking history, Charlson comorbidity index (CCI), hemoglobin, serum albumin, BNP, eGFR, etc. Multivariate logistic regression showed that age (OR 1.08, 95% CI 1.00–1.17, P=0.0390), Charlson comorbidity index (OR 4.75, 95% CI 1.17–19.30, P=0.0295), and serum albumin (OR 0.80, 95% CI 0.70–0.92, P=0.0012) were the independent risk factors of ADL impairment.

Conclusion

Decline of ADL in CKD patients was independently correlated with age, Charlson comorbidity index and serum albumin. ADL and its influential factors in the elderly CKD patients deserve further attention.

Association between the number of teeth and frailty among Chinese older adults: a nationwide cross-sectional study

OBJECTIVES

To explore the association between the number of teeth and frailty among older Chinese adults using a nationally representative sample.

DESIGN

Cross-sectional analysis was carried out using the 2014 wave data from the Chinese Longitudinal Healthy Longevity Survey, which used a targeted random-sampling design.

SETTING

This research was conducted in communities from nearly half of the counties and cities in 22 out of 31 provinces throughout China.

PARTICIPANTS

Of the 6934 interviewees aged ≥65 years, the final analysis included 3635 older adults who had completed the 2014 wave survey on the variables included in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Outcome variables included frailty, measured by the Frailty Index, and number of teeth. Covariates included demographic characteristics (ie, age, sex, co-residence, marital status, years of education and financial support), body mass index (BMI) and health behaviours (ie, smoking, drinking and exercise). A univariate logistic regression was used to test the factors associated with frailty. A multiple logistic regression model was used, using the frailty score as the dependent variable and the number of teeth together with significant covariates as the independent variables.

RESULTS

The prevalence of frailty was 27.68%. The mean number of teeth present was 9.23 (SD=10.03). The multiple logistic regression showed that older adults' demographic variables, health behaviours, BMI, tooth number and chewing pain were significantly associated with frailty. After adjusting for the covariates, older adults with fewer teeth had significantly higher odds of frailty than those with 20 or more teeth (no teeth: OR=2.07, 95% CI 1.53 to 2.80; 1 to 10 teeth: OR=1.77, 95% CI 1.31 to 2.38), except for older adults with 11 to 20 teeth (OR=1.30, 95% CI 0.93 to 1.82).

CONCLUSIONS

The presence of fewer teeth is significantly associated with frailty status among older Chinese adults. Future studies are needed to explain the specific mechanisms underlying how oral health status is associated with frailty.

High intensity interval training improves physical performance in aged female mice: A comparison of mouse frailty assessment tools

Frailty syndrome increases the risk for disability and mortality, and is a major health concern amidst the geriatric shift in the population. High intensity interval training (HIIT), which couples bursts of vigorous activity interspersed with active recovery intervals, shows promise for the treatment of frailty. Here we compare and contrast five Fried physical phenotype and one deficit accumulation based mouse frailty assessment tools for identifying the impacts of HIIT on frailty and predicting functional capacity, underlying pathology, and survival in aged female mice. Our data reveal a 10-minute HIIT regimen administered 3-days-a-week for 8-weeks increased treadmill endurance, gait speed and maintained grip strength. One frailty tool identified a benefit of HIIT for frailty, but many were trending suggesting HIIT was beneficial for physical performance in these mice, but the 8-week timeframe may have been insufficient to induce frailty benefits. Finally, most frailty tools distinguished between surviving or non-surviving mice, whereas half correlated with functional capacity measured by nest building ability, and none correlated with underlying pathology. In summary, this study supports the ongoing development of mouse assessment tools as useful instruments for frailty research.

The frailty index is a predictor of cause-specific mortality independent of familial effects from midlife onwards: a large cohort study

BACKGROUND

Frailty index (FI) is a well-established predictor of all-cause mortality, but less is known for cause-specific mortality and whether familial effects influence the associations. Middle-aged individuals are also understudied for the association between FI and mortality. Furthermore, the population mortality impact of frailty remains understudied.

METHODS

We estimated the predictive value of FI for all-cause and cause-specific mortality, taking into account familial factors, and tested whether the associations are time-dependent. We also assessed the proportion of all-cause and cause-specific deaths that are attributable to increased levels of frailty. We analyzed 42,953 participants from the Screening Across the Lifespan Twin Study (aged 41-95 years at baseline) with up to 20 years' mortality follow-up. The FI was constructed using 44 health-related items. Deaths due to cardiovascular disease (CVD), respiratory-related causes, and cancer were considered in the cause-specific analysis. Generalized survival models were used in the analysis.

RESULTS

Increased FI was associated with higher risks of all-cause, CVD, and respiratory-related mortality, with the corresponding hazard ratios of 1.28 (1.24, 1.32), 1.31 (1.23, 1.40), and 1.23 (1.11, 1.38) associated with a 10% increase in FI in male single responders, and 1.21 (1.18, 1.25), 1.27 (1.15, 1.34), and 1.26 (1.15, 1.39) in female single responders. No significant associations were observed for cancer mortality. No attenuation of the mortality associations in unrelated individuals was observed when adjusting for familial effects in twin pairs. The associations were time-dependent with relatively greater effects observed in younger ages. Before the age of 80, the proportions of deaths attributable to FI levels > 0.21 were 18.4% of all-cause deaths, 25.4% of CVD deaths, and 20.4% of respiratory-related deaths in men and 19.2% of all-cause deaths, 27.8% of CVD deaths, and 28.5% of respiratory-related deaths in women. After the age of 80, the attributable proportions decreased, most notably for all-cause and CVD mortality.

CONCLUSIONS

Increased FI predicts higher risks of all-cause, CVD, and respiratory-related mortality independent of familial effects. Increased FI presents a relatively greater risk factor at midlife than in old age. Increased FI has a significant population mortality impact that is greatest through midlife until the age of 80.

Ethnic differences in frailty: a cross-sectional study of pooled data from community-dwelling older persons in the Netherlands

OBJECTIVE

Few European studies examined frailty among older persons from diverse ethnic backgrounds. We aimed to examine the association of ethnic background with frailty. In addition, we explored the association of ethnic background with distinct components that are considered to be relevant for frailty.

DESIGN AND SETTING

This was a cross-sectional study of pooled data of The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS) in the Netherlands.

PARTICIPANTS

Community-dwelling persons aged 55 years and older with a Dutch, Indonesian, Surinamese, Moroccan or Turkish ethnic background were included (n=23 371).

MEASUREMENTS

Frailty was assessed with the validated TOPICS-Frailty Index that consisted of 45 items. The TOPICS-Frailty Index contained six components: morbidities, limitations in activities of daily living (ADL), limitations in instrumental ADL, health-related quality of life, psychosocial health and self-rated health. To examine the associations of ethnic background with frailty and with distinct frailty components, we estimated multilevel random-intercept models adjusted for confounders.

RESULTS

TOPICS-Frailty Index scores varied from 0.19 (SD=0.12) among persons with a Dutch background to 0.29 (SD=0.15) in persons with a Turkish background. After adjustment for age, sex, living arrangement and education level, persons with a Turkish, Moroccan or Surinamese background were frailer compared with persons with a Dutch background (p<0.001). There were no significant differences in frailty between persons with an Indonesian compared with a Dutch background. The IADL component scores were higher among all groups with a non-Dutch background compared with persons with a Dutch background (p<0.05 or lower for all groups).

CONCLUSIONS

Compared with older persons with a Dutch background, persons with a Surinamese, Moroccan or Turkish ethnic background were frailer. Targeted intervention strategies should be developed for the prevention and reduction of frailty among these older immigrants.

Finding the vulnerable among China's elderly: identifying measures for effective policy targeting

Facing a rapidly aging population, China has recently started to formulate and implement policies with the aim to provide old-age care. While well-developed old-age care policies commonly include a built-in component that assesses eligibility based on vulnerability, no such process is established in the context of China. Here, based on data from the China Health and Retirement Longitudinal Study collected in both 2011 and 2013, we (a) developed a simple and effective strategy for identifying vulnerable Chinese elderly, which can serve as a basis for policy targeting, and (b) improved the policy relevance and targeting efficiency of this vulnerability measure by including additional health indicators. Our vulnerability measures identify 35% to 46% of Chinese elderly as vulnerable, covering up to 67% of elderly at high risk of death or functional decline. They can serve as an initial screening step for more comprehensive geriatric assessments and enable policy makers to effectively target vulnerable elderly persons in China.

Frailty transitions and types of death in Chinese older adults: a population-based cohort study

Background

Little is known about the adverse effects of frailty transitions. In this study, we aimed to characterize the transitions between frailty states and examine their associations with the type of death among older adults in China, a developing country with a rapidly growing aging population.

Methods

We used data of 11,165 older adults (aged 65-99 years) from the 2002 and 2005 waves of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Overall, 44 health deficits were used to construct frailty index (FI; range: 0-1), which was then categorized into a three-level variable: nonfrail (FI ≤0.10), prefrail (0.10< FI ≤0.21), and frail (FI >0.21). Outcome was four types of death based on bedridden days and suffering state (assessed in the 2008 wave of CLHLS).

Results

During the 3-year period, 3,394 (30.4%) participants had transitioned between different frailty states (nonfrail, prefrail, and frail), one-third transitioned to death, and one-third remained in previous frailty states. Transitions to greater frailty (ie, "worsening") were more common than transitions to lesser frailty (ie, "improvement"). Among four categories of frailty transitions, "worsening" and "remaining frail" had increased risks of painful death, eg, with odds ratios of 1.92 (95% confidence interval [CI] =1.41, 2.62) and 4.75 (95% CI =3.32, 6.80), respectively, for type 4 death (ie, ≥30 bedridden days with suffering before death).

Conclusion

This large sample of older adults in China supports that frailty is a dynamic process, characterized by frequent types of transitions. Furthermore, those who remained frail had the highest likelihood of experiencing painful death, which raises concerns about the quality of life in frail populations.

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

OBJECTIVE

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

METHODS

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

RECOMMENDATIONS

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

CONCLUSIONS

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

Toward Using a Smartwatch to Monitor Frailty in a Hospital Setting: Using a Single Wrist-Wearable Sensor to Assess Frailty in Bedbound Inpatients

BACKGROUND

While various objective tools have been validated for assessing physical frailty in the geriatric population, these are often unsuitable for busy clinics and mobility-impaired patients. Recently, we have developed a frailty meter (FM) using two wearable sensors, which allows capturing key frailty phenotypes (weakness, slowness, and exhaustion), by testing 20-s rapid elbow flexion-extension test.

OBJECTIVE

In this study, we proposed an enhanced automated algorithm to identify frailty using a single wrist-worn sensor.

METHODS

The data collected from 100 geriatric inpatients (age: 78.9 ± 9.1 years, 49% frail) were reanalyzed to validate the new algorithm. The frailty status of the participants was determined using a validated modified frailty index. Different FM phenotypes (31 features) including velocity of elbow rotation, decline in velocity of elbow rotation over 20 s, range of motion, etc. were extracted. A regression model, bootstrap with 2,000 iterations, and recursive feature elimination technique were used for optimizing the FM parameters and identifying frailty using a single wrist-worn sensor.

RESULTS

A strong agreement was observed between two-sensor and wrist-worn sensor configuration (r = 0.87, p < 0.001). Results suggest that the wrist-worn FM with no demographic information still yields a high accuracy of 80.0% (95% CI: 79.7-80.3%) and an area under the curve of 87.7% (95% CI: 87.4-87.9%) to identify frailty status. Results are comparable with two-sensor configuration, where the observed accuracy and area under the curve were 80.6% (95% CI: 80.4-80.9%) and 87.4% (95% CI: 87.1-87.6%), respectively.

CONCLUSION

The simplicity of FM may open new avenues to integrate wearable technology and mobile health to capture frailty status in a busy hospital setting. Furthermore, the reduction of needed sensors to a single wrist-worn sensor allows deployment of the proposed algorithm in the form of a smartwatch application. From the application standpoint, the proposed FM is superior to traditional physical frailty-screening tools in which the walking test is a key frailty phenotype, and thus they cannot be used for bedbound patients or in busy clinics where administration of gait test as a part of routine assessment is impractical.

Socioeconomic inequalities in frailty and frailty components among community-dwelling older citizens

BACKGROUND

So far, it has not yet been studied whether socioeconomic status is associated with distinct frailty components and for which frailty component this association is the strongest. We aimed to examine the association between socioeconomic status and frailty and frailty components. In addition we assessed the mediating effect of the number of morbidities on the association between socioeconomic status and other frailty components.

METHODS

This is a cross-sectional study of pooled data of The Older Persons and Informal Caregivers Survey Minimum DataSet in the Netherlands among community-dwelling persons aged 55 years and older (n = 26,014). Frailty was measured with a validated Frailty Index that consisted of 45 items. The Frailty Index contained six components: morbidities, limitations in activities of daily living (ADL), limitations in instrumental ADL (IADL), health-related quality of life, psychosocial health and self-rated health. Socioeconomic indicators used were education level and neighbourhood socioeconomic status.

RESULTS

Persons with primary or secondary education had higher overall frailty and frailty component scores compared to persons with tertiary education (P < .001). Lower education levels were most consistently associated with higher overall frailty, more morbidities and worse self-rated health (P < .05 in all age groups). The strongest association was found between primary education and low psychosocial health for persons aged 55-69 years and more IADL limitations for persons aged 80+ years. Associations between neighborhood socioeconomic status and frailty (components) also showed inequalities, although less strong. The number of morbidities moderately to strongly mediated the association between socioeconomic indicators and other frailty components.

CONCLUSION

There are socioeconomic inequalities in frailty and frailty components. Inequalities in frailty, number of morbidities and self-rated health are most consistent across age groups. The number of morbidities a person has play an important role in explaining socioeconomic inequalities in frailty and should be taken into account in the management of frailty.

Frailty and Its Contributory Factors in Older Adults: A Comparison of Two Asian Regions (Hong Kong and Taiwan)

This study aimed to compare the prevalence of frailty across three Chinese populations: Hong Kong, Taiwan-urban and Taiwan-rural. Contributing factors to disparities in frailty were also examined. Data were derived from the Osteoporotic Fractures in Men (MrOs) and Women (MsOs) (Hong Kong) Study (n = 4000) and the Taiwan Longitudinal Study on Aging (n = 2392). Frailty was defined as an index calculated from 30 multiple deficits. The ratio of the frailty index to life expectancy at birth (FI/LE) was used as an indicator of compression of morbidity. Frailty was more prevalent in Taiwan-urban (33.1%) and Taiwan-rural (38.1%) compared to Hong Kong (16.6%, p < 0.05) and was higher in women (22.6–49.7%) than in men (10.5–27.5%, p < 0.05). The ratios of FI/LE were higher in Taiwan-urban and Taiwan-rural (both 0.27) compared to Hong Kong (0.20, p < 0.05). Multivariate analyses revealed that older age, being a woman and low levels of physical activity were common risk factors for frailty across the three populations. Alcohol use was inversely associated with frailty in both Hong Kong and Taiwan-urban populations, but not in Taiwan-rural. Living alone was associated with frailty in Hong Kong men, but not in Hong Kong women or Taiwanese people. For all study populations, older age and being a woman constituted the highest attributable factor. This comparison provides useful data to inform government policies.

Prevalence of frailty among community dwelling older adults in receipt of low level home support: a cross-sectional analysis of the North Dublin Cohort

BACKGROUND

There is increasing demand for formal government funded home help services to support community-dwelling older people in Ireland, yet limited information exists on the health profiles of this group, especially regarding frailty. Our aim was to profile a large cohort of adults in receipt of low level home help and to determine the prevalence of frailty.

METHODS

A total 1312 older adults, (≥ 65 years) in receipt of low level home help (< 5 h per week) were reviewed by community nurses and frailty was assessed using the Clinical Frailty Scale (CFS) in this cross-sectional study. Characteristics of the group were compared between males and females and prevalence of frailty was reported according to gender and principal care. Associations between frailty and a number of variables were explored using bivariate and regression analysis.

RESULTS

The cohort of low level home-help users was a mean age of 82.1 (SD 7.3) years, predominantly female (70.6%) and over half (69.2%) lived alone. The prevalence of frailty in this population was 41.5%, with subjects primarily considered mildly (23.2%) or moderately frail (14.5%) by the CFS. A further 38.4% were classed as vulnerable. The degree of frailty did not differ significantly across the younger categories aged 65-84 years. However, in the oldest age groups, namely 90-94 and >95 years, moderate frailty was significantly higher relative to the younger groups (21% and 34%, p < 0.05, p < 0.01 respectively). Home help hours significantly correlated with frailty (rs = 0.371, p < 0.001) and functional dependency (rs = 0.609, p < 0.001), but only weakly with age (rs = 0.101, p = 0.034). Based on regression analysis, determinants of frailty included greater dependency (Barthel score), higher home help hours, non-self-caring and communication difficulty, all of which significantly contributed to the model, with a r squared value of 0.508.

CONCLUSION

A high prevalence of frailty (41.5%) was documented in this population which associated with higher home help utilisation. Frailty was associated with greater functional dependency, but not strongly with chronological age, until after 90 years. These findings highlight opportunities for developing intervention strategies targeted at ageing in place among home help users.