The dynamics of frailty development and progression in older adults in primary care in England (2006-2017): a retrospective cohort profile

Longevity as a Responsibility: Constructing Healthy Aging by Enacting within Contexts over the Entire Lifespan

Studying aging now requires going beyond the bio-psycho-social model and incorporating a broader multidisciplinary view capable of capturing the ultimate complexity of being human that is expressed as individuals age. Current demographic trends and the lengthening of life expectancies allow the observation of long-lived individuals in full health. These super-agers are no longer an exception. Indeed, individuals can have a good quality of life even over age 70 and living with chronic or neurodegenerative diseases. This change is driven in part by the cohort effect observed in people who are about to age today (e.g., better schooling, more advanced health conditions, and technologization) but more so by the gradual overcoming of ageist views. An aged person is no longer seen as a quitter but rather as one empowered to direct their own trajectory of potentially healthy longevity. According to this vision, this article proposes a situated lifespan perspective for the study of aging that integrates pedagogical models of developmental ecology with psychological theories of optimal experience to understand the individual motivational perspective on aging. At the same time, it does not disregard analyzing the daily and cultural contexts in which everyone situates and that guide aging trajectories. Nor does it forget that aging people are body-mind (embodied) organisms that, with contexts and through motivations, seize opportunities for action (affordances) to evolve in an optimal way during their lifespan. This theoretical reflection sheds new light on the aging process and on future trends in healthy longevity research.

Frailty progression in adults aged 40 years and older in rural Burkina Faso: a longitudinal, population-based study

BACKGROUND

Little is known about ageing and frailty progression in low-income settings. We aimed to describe frailty changes over time in individuals living in rural Burkina Faso and to assess which sociodemographic, disability, and multimorbidity factors are associated with frailty progression and mortality.

METHODS

This longitudinal, population-based study was conducted at the Nouna Health and Demographic Surveillance Systems (HDSS) site in northwestern Burkina Faso. Eligible participants were aged 40 years or older and had been primarily resident in a household within the HDSS area for at least the past 6 months before the baseline survey and were selected from the 2015 HDSS household census using a stratified random sample of adults living in unique households within the area. Participants were interviewed in their homes in 2018 (baseline), 2021 (follow-up), or both. We derived the Fried frailty score for each participant at each timepoint using data on grip strength, gait speed, self-reported weight loss, self-reported exhaustion, and physical activity, and described changes in frailty status (no frailty, pre-frailty, or frailty) between 2018 and 2021. We used multivariate regression models to assess factors (ie, sex, age, marital status, educational attainment, wealth quintile, WHO Disability Assessment Schedule (WHODAS) score, and multimorbidity) associated with frailty progression (either worsening frailty status or dying, compared with frailty status remaining the same or improving) and with mortality, and developed sequential models: unadjusted, adjusting for sociodemographic factors (sex, age, marital status, educational attainment, and wealth quintile), and adjusting for sociodemographic factors, disability, and multimorbidity.

FINDINGS

Between May 25 and July 19, 2018, and between July 1 and Aug 22, 2021, 5952 individuals were invited to participate: 1709 (28·7%) did not consent, 1054 (17·8%) participated in 2018 only and were lost to follow-up, 1214 (20·4%) participated in 2021 only, and 1975 (33·2%) were included in both years or died between years. Of 1967 participants followed up with complete demographic data, 190 (9·7%) were frail or unable to complete the frailty assessment in 2018, compared with 77 (3·9%) in 2021. Between 2018 and 2021, frailty status improved in 567 (28·8%) participants and worsened in 327 (16·6%), and 101 (5·1%) participants died. The relative risk of frailty status worsening or of dying (compared with frailty impRoving or no change) increased with age and WHODAS score, whereas female sex appeared protective. After controlling for all sociodemographic factors, multimorbidity, and WHODAS score, odds of mortality were 1·07 (odds ratio 2·07, 95% CI 1·05-4·09) times higher among pre-frail individuals and 1·1 (2·21, 0·90-5·41) times higher among frail individuals than among non-frail individuals.

INTERPRETATION

Frailty status was highly dynamic in this low-income setting and appears to be modifiable. Given the rapid increase in the numbers of older adults in low-income or middle-income countries, understanding the behaviour of frailty in these settings is of high importance for the development of policies and health systems to ensure the maintenance of health and wellbeing in ageing populations. Future work should focus on designing context-appropriate interventions to improve frailty status.

FUNDING

Alexander Von Humboldt Foundation, Institute for Global Innovation, University of Birmingham, and Wellcome Trust.

Multidisciplinary, multicomponent interventions to reduce frailty among older persons in residents of residential care facilities: a scoping review

BACKGROUND

Frailty reduction and reversal have been addressed successfully among older populations within community settings. However, these findings may not be applicable to residential care settings, largely due to the complex and multidimensional nature of the condition. Relatively, few attempts at frailty prevention exist in residential settings. This review aims to identify and describe best practice models of care for addressing frailty among older populations in residential care settings. This research also sets out to explore the impact of multidisciplinary health service delivery models on health outcomes such as mortality, hospitalisations, quality of life, falls and frailty.

METHODS

A scoping review of the literature was conducted to address the project objectives. Reference lists of included studies, bibliographic databases and the grey literature were systematically searched for literature reporting multidisciplinary, multidimensional models of care for frailty.

RESULTS

The scoping review found no interventions that met the inclusion criteria. Of the 704 articles screened, 664 were excluded as not relevant. Forty articles were fully assessed, and while no eligible studies were found, relevant data were extracted from 10 near-eligible studies that reported single disciplines or single dimensions rather than a model of care. The physical, nutritional, medicinal, social and cognitive aspects of the near eligible studies have been discussed as playing a key role in frailty reduction or prevention care models.

CONCLUSION

This review has identified a paucity of interventions for addressing and reducing frailty in residential care settings. High-quality studies investigating novel models of care for addressing frailty in residential care facilities are required to address this knowledge gap. Similarly, there is a need to develop and validate appropriate screening and assessment tools for frailty in residential care populations. Health service providers and policy-makers should also increase their awareness of frailty as a dynamic and reversible condition. While age is a non-modifiable predictor of frailty, addressing modifiable factors through comprehensive care models may help manage and prevent the physical, social and financial impacts of frailty in the ageing population.

Impact of frailty in patients with non-valvular atrial fibrillation undergoing catheter ablation

Background

The relationships between frailty and clinical outcomes in elderly Japanese patients with non-valvular atrial fibrillation (NVAF) after catheter ablation (CA) have not been established. We evaluated the frailty rate of patients undergoing CA for NVAF, examined whether CA for NVAF improves frailty, and analyzed the CA outcomes of patients with and without frailty.

Methods

Elderly Japanese patients (≥65 years; mean age: 72.8 years) who participated in the real-world ablation therapy with anti-coagulants in management of atrial fibrillation registry and who responded to the frailty screening index survey were included (n = 213). Frailty and AF recurrence were assessed preoperatively and at 3 and 6 months after CA.

Results

Twenty-six patients (12.8%) were frail, 109 (53.7%) were pre-frail, and 68 (33.5%) were robust. Cardiovascular (frailty: 0.5%/person-year; pre-frailty: 0.1%/person-year; robust: 0.1%/person-year) and cardiac (frailty: 0.5%/person-year; pre-frailty: 0.1%/person-year; robust: 0.1%/person-year) events, as well as major bleeding (frailty: 0.3%/person-year; pre-frailty: 0.1%/person-year; robust: 0.1%/person-year), were numerically more frequent in the frailty group. No deaths from cardiovascular or stroke/systemic thromboembolic events occurred. A large proportion of patients did not experience 3-month (frailty: 96.2%; pre-frailty: 96.3%; robust: 88.2%) or 6-month (frailty: 88.5%; pre-frailty: 91.7%; robust: 86.8%) AF recurrence after CA. Weight loss, walking speed, and fatigue improved in the frailty and pre-frailty groups after CA.

Conclusion

Japanese patients aged ≥65 years with frailty or pre-frailty had improved frailty screening index components, such as weight loss, walking speed and fatigue, after CA. Therefore, elderly patients with frailty or pre-frailty may benefit from CA for NVAF.

AZD1222 effectiveness against severe COVID-19 in individuals with comorbidity or frailty: The RAVEN cohort study

OBJECTIVES

Despite being prioritized during initial COVID-19 vaccine rollout, vulnerable individuals at high risk of severe COVID-19 (hospitalization, intensive care unit admission, or death) remain underrepresented in vaccine effectiveness (VE) studies. The RAVEN cohort study (NCT05047822) assessed AZD1222 (ChAdOx1 nCov-19) two-dose primary series VE in vulnerable populations.

METHODS

Using the Oxford-Royal College of General Practitioners Clinical Informatics Digital Hub, linked to secondary care, death registration, and COVID-19 datasets in England, COVID-19 outcomes in 2021 were compared in vaccinated and unvaccinated individuals matched on age, sex, region, and multimorbidity.

RESULTS

Over 4.5 million AZD1222 recipients were matched (mean follow-up ∼5 months); 68% were ≥50 years, 57% had high multimorbidity. Overall, high VE against severe COVID-19 was demonstrated, with lower VE observed in vulnerable populations. VE against hospitalization was higher in the lowest multimorbidity quartile (91.1%; 95% CI: 90.1, 92.0) than the highest quartile (80.4%; 79.7, 81.1), and among individuals ≥65 years, higher in the 'fit' (86.2%; 84.5, 87.6) than the frailest (71.8%; 69.3, 74.2). VE against hospitalization was lowest in immunosuppressed individuals (64.6%; 60.7, 68.1).

CONCLUSIONS

Based on integrated and comprehensive UK health data, overall population-level VE with AZD1222 was high. VEs were notably lower in vulnerable groups, particularly the immunosuppressed.

Primary and secondary care service use and costs associated with frailty in an ageing population: longitudinal analysis of an English primary care cohort of adults aged 50 and over, 2006-2017

BACKGROUND

Frailty becomes more prevalent and healthcare needs increase with age. Information on the impact of frailty on population level use of health services and associated costs is needed to plan for ageing populations.

AIM

To describe primary and secondary care service use and associated costs by electronic Frailty Index (eFI) category.

DESIGN AND SETTING

Retrospective cohort using electronic health records. Participants aged ≥50 registered in primary care practices contributing to the Oxford Royal College of General Practitioners Research and Surveillance Centre, 2006-2017.

METHODS

Primary and secondary care use (totals and means) were stratified by eFI category and age group. Standardised 2017 costs were used to calculate primary, secondary and overall costs. Generalised linear models explored associations between frailty, sociodemographic characteristics. Adjusted mean costs and cost ratios were produced.

RESULTS

Individual mean annual use of primary and secondary care services increased with increasing frailty severity. Overall cohort care costs for were highest in mild frailty in all 12 years, followed by moderate and severe, although the proportion of the population with severe frailty can be expected to increase over time. After adjusting for sociodemographic factors, compared to the fit category, individual annual costs doubled in mild frailty, tripled in moderate and quadrupled in severe.

CONCLUSIONS

Increasing levels of frailty are associated with an additional burden of individual service use. However, individuals with mild and moderate frailty contribute to higher overall costs. Earlier intervention may have the most potential to reduce service use and costs at population level.

The Long-Term Impact of Frailty After an Intensive Care Unit Admission Due to Chronic Obstructive Pulmonary Disease

Rationale

Frailty is an increasingly recognized aspect of chronic obstructive pulmonary disease (COPD). The impact of frailty on long-term survival after admission to an intensive care unit (ICU) due to an exacerbation of COPD has not been described.

Objective

The objective was to quantify the impact of frailty on time to death up to 4 years after admission to the ICU in Australia and New Zealand for an exacerbation of COPD.

Methods

We performed a multicenter retrospective cohort study of adult patients admitted to 179 ICUs with a primary diagnosis of an exacerbation of COPD using the Australian and New Zealand Intensive Care Society Adult Patient Database from January 1, 2018, through December 31, 2020, in New Zealand, and March 31, 2022, in Australia. Frailty was measured using the clinical frailty scale (CFS). The primary outcome was survival up to 4 years after ICU admission. The secondary outcome was readmission to the ICU due to an exacerbation of COPD.

Measurements and Main Results

We examined 7126 patients of which 3859 (54.1%) were frail (CFS scores of 5-8). Mortality in not-frail individuals versus frail individuals at 1 and 4 years was 19.8% versus 40.4%, and 56.8% versus 77.3% respectively (both p<0.001). Frailty was independently associated with a shorter time to death (adjusted hazard ratio 1.66; 95% confidence interval 1.54-1.80).There was no difference in the proportion of survivors with or without frailty who were readmitted to the ICU during a subsequent hospitalization.

Conclusions

Frailty was independently associated with poorer long-term survival in patients admitted to the ICU with an exacerbation of COPD.

Current evidence on the association of tongue strength with cognitive decline in older adults and the known risk factors of frailty, sarcopenia and nutritional health: a scoping review protocol

INTRODUCTION

Evidence suggests that the pathology underlying cognitive decline leading to dementia begins 15-20 years before cognitive symptoms emerge. Thus, identifying biomarkers in this preclinical phase is critically important. Age-related decrease in muscle mass and strength, a known risk factor for sarcopenia, frailty and cognitive decline, also affects the tongue. This paper describes an a priori protocol by a multidisciplinary team to address the following questions relating to adults ≥50 years of age: (1) What is the current evidence on the association of tongue strength with cognitive decline? (2) How does tongue strength associate with frailty and sarcopenia? (3) What is the association of tongue strength with nutritional health?

METHODS AND ANALYSIS

Search terms will be identified then multiple electronic databases (PubMed, PsycINFO (Ovid), Scopus, Embase (Ovid), CINAHL and Web of Science) searched systematically for peer-reviewed articles published in English that address the following inclusion criteria: (1) human studies, (2) participants ≥50 years of age and (3) studies with tongue pressure values measured in relation to at least one of the following: frailty, sarcopenia, nutritional health, cognitive function and dementia (Alzheimer's, vascular, frontotemporal and Lewy body). Grey literature also will be searched to identify additional studies, clinical trials and policy papers appropriate for inclusion. The search will be from database inception. After removing duplicates, two research team members will independently screen abstracts and identify articles for full-text review. The team will use a data charting tool for data extraction. Data will be analysed quantitatively and qualitatively.

ETHICS AND DISSEMINATION

The scoping review does not require ethics approval as data will be from publicly available sources. Results will be disseminated in workshops and conferences and a peer-reviewed journal paper.

The Association of Pain with Incident Falls in People with Chronic Obstructive Pulmonary Disease: Evidence from the English Longitudinal Study of Ageing

People with chronic obstructive pulmonary disease (COPD) have a higher prevalence of pain and a greater risk of falls than their healthy peers. As pain has been associated with an increased risk of falls in older adults, this study investigated the association between pain and falls in people with COPD compared to healthy controls. Data from the English Longitudinal Study of Ageing were used to establish an association between pain and falls when modelled with a generalised ordinal logistic regression and adjusted for sex, age, wealth, and education (complete case analysis only; n = 806 COPD, n = 3898 healthy controls). The odds were then converted to the predicted probabilities of falling. The predicted probability of falling for people with COPD was greater across all pain categories than for healthy controls; for COPD with (predicted probability % [95%CI]), no pain was 20% [17 to 25], with mild pain was 28% [18 to 38], with moderate pain was 28% [22 to 34] with severe pain was 39% [30 to 47] and for healthy controls with no pain was 17% [16 to 18], mild pain 22% [18 to 27], moderate pain 25% [20 to 29] and severe pain 27% [20 to 35]. The probability of falling increased across pain categories in individuals with COPD, with the most severe pain category at a nearly 40% probability of falling, indicating a potential interaction between COPD and pain.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Current Treatment Options and the Role of Functional Status Assessment in Classical Hodgkin Lymphoma in Older Adults: A Review

Along with the fact that classical Hodgkin lymphoma (cHL) in older adults is frequently considered biologically different from cHL in younger patients, its most distinctive feature is its dismal clinical outcome due to the decreased effectiveness and greater toxicity of therapies. Although strategies to mitigate specific toxicities (e.g., cardiological and pulmonary) have obtained some results, in general, reduced-intensity schemes, proposed as an alternative to ABVD, have proved to be less effective. The addition of brentuximab vedotin (BV) to AVD, especially in a sequential scheme, has demonstrated good efficacy. However, the problem of toxicity persists even with this new therapeutic combination, with comorbidities remaining an important prognostic factor. The adequate stratification of functional status is necessary to distinguish between those patients who will benefit from full treatment and those who will benefit from alternative strategies. A simplified geriatric assessment based on the determination of ADL (activity of daily living), IADL (instrumental ADL), and CIRS-G (Cumulative Illness Rating Scale-Geriatric) scores is an easy-to-use tool that permits adequate patient stratification. Other factors of considerable impact on functional status such as sarcopenia and immunosenescence are currently being studied. A fitness-based treatment choice would also be very useful for relapsed or refractory patients, a more frequent and challenging situation than that is found in young cHL patients.

Representativeness, Vaccination Uptake, and COVID-19 Clinical Outcomes 2020-2021 in the UK Oxford-Royal College of General Practitioners Research and Surveillance Network: Cohort Profile Summary

BACKGROUND

The Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) is one of Europe's oldest sentinel systems, working with the UK Health Security Agency (UKHSA) and its predecessor bodies for 55 years. Its surveillance report now runs twice weekly, supplemented by online observatories. In addition to conducting sentinel surveillance from a nationally representative group of practices, the RSC is now also providing data for syndromic surveillance.

OBJECTIVE

The aim of this study was to describe the cohort profile at the start of the 2021-2022 surveillance season and recent changes to our surveillance practice.

METHODS

The RSC's pseudonymized primary care data, linked to hospital and other data, are held in the Oxford-RCGP Clinical Informatics Digital Hub, a Trusted Research Environment. We describe the RSC's cohort profile as of September 2021, divided into a Primary Care Sentinel Cohort (PCSC)-collecting virological and serological specimens-and a larger group of syndromic surveillance general practices (SSGPs). We report changes to our sampling strategy that brings the RSC into alignment with European Centre for Disease Control guidance and then compare our cohort's sociodemographic characteristics with Office for National Statistics data. We further describe influenza and COVID-19 vaccine coverage for the 2020-2021 season (week 40 of 2020 to week 39 of 2021), with the latter differentiated by vaccine brand. Finally, we report COVID-19-related outcomes in terms of hospitalization, intensive care unit (ICU) admission, and death.

RESULTS

As a response to COVID-19, the RSC grew from just over 500 PCSC practices in 2019 to 1879 practices in 2021 (PCSC, n=938; SSGP, n=1203). This represents 28.6% of English general practices and 30.59% (17,299,780/56,550,136) of the population. In the reporting period, the PCSC collected >8000 virology and >23,000 serology samples. The RSC population was broadly representative of the national population in terms of age, gender, ethnicity, National Health Service Region, socioeconomic status, obesity, and smoking habit. The RSC captured vaccine coverage data for influenza (n=5.4 million) and COVID-19, reporting dose one (n=11.9 million), two (n=11 million), and three (n=0.4 million) for the latter as well as brand-specific uptake data (AstraZeneca vaccine, n=11.6 million; Pfizer, n=10.8 million; and Moderna, n=0.7 million). The median (IQR) number of COVID-19 hospitalizations and ICU admissions was 1181 (559-1559) and 115 (50-174) per week, respectively.

CONCLUSIONS

The RSC is broadly representative of the national population; its PCSC is geographically representative and its SSGPs are newly supporting UKHSA syndromic surveillance efforts. The network captures vaccine coverage and has expanded from reporting primary care attendances to providing data on onward hospital outcomes and deaths. The challenge remains to increase virological and serological sampling to monitor the effectiveness and waning of all vaccines available in a timely manner.

Transitions in frailty state 12 months after kidney transplantation: a prospective cohort study

BACKGROUND

Frailty is associated with several unfavorable outcomes after kidney transplantation (KTx). However, limited information is available regarding the transitions in frailty state and its components after KTx. This study aimed to evaluate the transitions in physical frailty phenotype and its components over a period of 12 months after KTx.

METHODS

In this prospective single-center cohort study, we measured physical frailty phenotype (PFP) and its components at the time of admission for KTx and 12 months after KTx. The evaluation includes five components: weakness (grip strength analysed by sex and body mass index quartiles), physical activity (kcals/week based on the Minnesota Leisure Time Physical Activity questionnaire), exhaustion (self-report using the Center for Epidemiological Studies Depression Scale), gait speed (time taken to walk 15 feet based on sex and height-specific cutoff), and unintentional weight loss (self-report of unintentional weight loss > 10 lbs in the last year). The exhaustion and physical activity components are validated in the Brazilian population. Each component is scored as 0 or 1 according to its presence or absence, and a PFP score of 3-5 defines frailty, 2 is intermediate, and 0-1 is rated as non-frail. We used the McNemar and Wilcoxon test to compare physical frailty phenotype and its components between the two periods.

RESULTS

Among 87 patients included in the study, 16.1% were classified as frail, 20.7% as intermediately frail, and 63.2% as non-frail. Sixty-four patients were included in the analysis to evaluate transitions in frailty. At the time of admission for KTx, 15.6% of patients were defined as frail compared to 4.7% of patients at 12 months after KTx (p = 0.023). Among the physical frailty phenotype components, the proportion of patients who scored in the weight loss category 12 months after KTx was significantly lower than that at the time of KTx (6.3% vs 34.4%, p < 0.001).

CONCLUSIONS

There was a 69.9% reduction in the prevalence of frail patients at the end of the 12-month follow-up after KTx. Among the components of frailty, weight loss showed a significant improvement.

Identifying Frail Patients by Using Electronic Health Records in Primary Care: Current Status and Future Directions

With the rapidly aging population, frailty, characterized by an increased risk of adverse outcomes, has become a major public health problem globally. Several frailty guidelines or consensuses recommend screening for frailty, especially in primary care settings. However, most of the frailty assessment tools are based on questionnaires or physical examinations, adding to the clinical workload, which is the major obstacle to converting frailty research into clinical practice. Medical data naturally generated by routine clinical work containing frailty indicators are stored in electronic health records (EHRs) (also called electronic health record (EHR) data), which provide resources and possibilities for frailty assessment. We reviewed several frailty assessment tools based on primary care EHRs and summarized the features and novel usage of these tools, as well as challenges and trends. Further research is needed to develop and validate frailty assessment tools based on EHRs in primary care in other parts of the world.