Comparing the prognostic value of geriatric health indicators: a population-based study

Validation of the Health Assessment Tool (HAT) based on four aging cohorts from the Swedish National study on Aging and Care

BACKGROUND

As global aging accelerates, routinely assessing the functional status and morbidity burden of older patients becomes paramount. The aim of this study is to assess the validity of the comprehensive clinical and functional Health Assessment Tool (HAT) based on four cohorts of older adults (60 + years) from the Swedish National study on Aging and Care (SNAC) spanning urban, suburban, and rural areas.

METHODS

The HAT integrates five health indicators (gait speed, global cognition, number of chronic diseases, and basic and instrumental activities of daily living), providing an individual-level score between 0 and 10. The tool was constructed using nominal response models, first separately for each cohort and then in a harmonized dataset. Outcomes included all-cause mortality over a maximum follow-up of 16 years and unplanned hospital admissions over a maximum of 3 years of follow-up. The predictive capacity was assessed through the area under the curve (AUC) using logistic regressions. For time to death, Cox regressions were performed, and Harrell's C-indices were reported. Results from the four cohorts were pooled using individual participant data meta-analysis and compared with those from the harmonized dataset.

RESULTS

The HAT demonstrated high predictive capacity across all cohorts as well as in the harmonized dataset. In the harmonized dataset, the AUC was 0.84 (95% CI 0.81-0.87) for 1-year mortality, 0.81 (95% CI 0.80-0.83) for 3-year mortality, 0.80 (95% CI 0.79-0.82) for 5-year mortality, 0.69 (95% CI 0.67-0.70) for 1-year unplanned admissions, and 0.69 (95% CI 0.68-0.70) for 3-year unplanned admissions. The Harrell's C for time-to-death throughout 16 years of follow-up was 0.75 (95% CI 0.74-0.75).

CONCLUSIONS

The HAT is a highly predictive, clinically intuitive, and externally valid instrument with potential for better addressing older adults' health needs and optimizing risk stratification at the population level.

Effects of the bio-psycho-social frailty dimensions on healthcare utilisation among elderly in Europe: A cross-country longitudinal analysis

Frailty represents an emerging challenge and has major implications for clinical practice, public health, and the sustainability of health systems. It is a geriatric condition, related to but distinct from disability and multimorbidity and characterized by a diminished physiological reserve of multiple organs. Despite limited consensus and evidence, it has been argued that cognitive and social aspects influence the condition. Therefore, we aim to provide evidence on the importance of taking a broader approach in defining frailty, by investigating the role of its physical, social, and psychological subdomains to predict healthcare utilisation in elderly Europeans. The study is based on the Survey of Health, Ageing and Retirement in Europe (SHARE), and uses 185,169 total observations from 12 European countries included in wave 4, 5, 6, and 8. The analysis investigates the influence of the physical frailty index (a proxy of the Frailty Phenotype definition), psychological and social frailty indexes (built to proxy the Tilburg Frailty Index) on the likelihood of hospitalisation and the number of doctor visits. We addressed missing values due to item non-response with fully conditional specification multivariate imputation and exploited the longitudinal structure of the data to control for time-fixed unobserved characteristics. In addition, our two multivariate models included regressors to correct for demand side factors (health status, socio-economic status, and behavioral risk) as well as for country-specific characteristics. Physical and psychological frailty positively influence the likelihood of hospitalisation (OR = 1.90 and OR = 1.31, respectively) and the number of doctor visits (IRR = 1.30 and IRR = 1.07), while social frailty reduces the two types of health services utilisation (OR = 0.53 and IRR = 0.90). The three frailty dimensions are relevant risk stratification factors in elderly Europeans, and health policies should focus more on the psycho-social aspects of this condition, as a strategy to both contain expenditures and avoid potential healthcare inequalities.

The prognostic value of the NECPAL instrument, Palliative Prognostic Index, and PROFUND index in elderly residents of nursing homes with advanced chronic condition

BACKGROUND

It is essential to assess the need for palliative care and the life prognosis of elderly nursing home residents with an advanced chronic condition, and the NECPAL ICO-CCOMS©4.0 prognostic instrument may be adequate for both purposes. The objective of this study was to examine the predictive capacity of NECPAL, the Palliative Prognosis Index, and the PROFUND index in elderly residents with advanced chronic condition with and without dementia, comparing their results at different time points.

METHODS

This prospective observational study was undertaken in eight nursing homes, following the survival of 146 residents with advanced chronic condition (46.6% with dementia) at 3, 6, 12, and 24 months. The capacity of the three instruments to predict mortality was evaluated by calculating the area under the receiver operating characteristic curve (AUC), with 95% confidence interval, for the global population and separately for residents with and without dementia.

RESULTS

The mean age of residents was 84.63 years (± 8.989 yrs); 67.8% were female. The highest predictive capacity was found for PROFUND at 3 months (95%CI: 0.526-0.756; p = 0.016), for PROFUND and NECPAL at 12 months (non-significant; AUC > 0.5), and NECPAL at 24 months (close-to-significant (AUC = 0.624; 95% CI: 0.499-0.750; p = 0.053). The highest capacity at 12 months was obtained using PROFUND in residents with dementia (AUC = 0.698; 95%CI: 0.566-0.829; p = 0.003) and NECPAL in residents without dementia (non-significant; AUC = 0.649; 95%CI: 0.432-0.867; p = 0.178). Significant differences in AUC values were observed between PROFUND at 12 (p = 0.017) and 24 (p = 0.028) months.

CONCLUSIONS

PROFUND offers the most accurate prediction of survival in elderly care home residents with advanced chronic condition overall and in those with dementia, especially over the short term, whereas NECPAL ICO-CCOMS©4.0 appears to be the most useful to predict the long-term survival of residents without dementia. These results support early evaluation of the need for palliative care in elderly care home residents with advanced chronic condition.

A Scoping Review of the Predictive Qualities of Walking Speed in Older Adults

BACKGROUND AND PURPOSE

Walking speed (WS) is an easily assessable and interpretable functional outcome measure with great utility for the physical therapist providing care to older adults. Since WS was proposed as the sixth vital sign, research into its interpretation and use has flourished. The purpose of this scoping review is to identify the current prognostic value of WS for the older adult.

METHODS

A scoping review was conducted using PubMed, CINAHL, and SPORTDiscus to find relevant articles highlighting the predictive capabilities of WS for older adults. Titles and abstracts were reviewed to identify relevant articles. Articles were excluded based on the following criteria: sample included both younger and older adults without separate analyses, sample was focused on a particular disease, if the study was published before 2017, or if the study did not report relevant cut points for interpretation of WS. The search returned 1064 results. Following removal of articles not meeting inclusion criteria and critical appraisal, relevant cut points were extracted from 47 original research publications.

RESULTS AND DISCUSSION

A preliminary review of the included articles showed that WS is a valuable prognostic tool across many health domains, including mental health, mortality, disability, pain, bone and joint health, falls, cognition, physical activity, metabolic health, risk for cardiovascular disease, socialization, and metabolic health. The fastest WS of 1.32 meters per second (m/s) served as a cutoff for decreased risk for incident development of type 2 diabetes, while the slowest WS of less than 0.2 m/s was associated with increased duration of hospitalization. Multiple studies reported on the prognostic value of WS slower than 1.0 m/s.

CONCLUSION

Although the reported range of predictive WS values was broad, multiple studies found WS of approximately 1.0 m/s to be a useful marker for delineating risk or decline across a variety of health domains. Clinicians may find it useful to use a WS slower than 1.0 m/s as a "yellow flag" to guide evaluation and intervention for their older adult clients.

Frailty detection among primary care older patients through the Primary Care Frailty Index (PC-FI)

The prompt identification of frailty in primary care is the first step to offer personalized care to older individuals. We aimed to detect and quantify frailty among primary care older patients, by developing and validating a primary care frailty index (PC-FI) based on routinely collected health records and providing sex-specific frailty charts. The PC-FI was developed using data from 308,280 primary care patients ≥ 60 years old part of the Health Search Database (HSD) in Italy (baseline 2013-2019) and validated in the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K; baseline 2001-2004), a well-characterized population-based cohort including 3363 individuals ≥ 60 years old. Potential health deficits part of the PC-FI were identified through ICD-9, ATC, and exemption codes and selected through an optimization algorithm (i.e., genetic algorithm), using all-cause mortality as the main outcome for the PC-FI development. The PC-FI association at 1, 3 and 5 years, and discriminative ability for mortality and hospitalization were tested in Cox models. The convergent validity with frailty-related measures was verified in SNAC-K. The following cut-offs were used to define absent, mild, moderate and severe frailty: < 0.07, 0.07-0.14, 0.14-0.21, and ≥ 0.21. Mean age of HSD and SNAC-K participants was 71.0 years (55.4% females). The PC-FI included 25 health deficits and showed an independent association with mortality (hazard ratio range 2.03-2.27; p < 0.05) and hospitalization (hazard ratio range 1.25-1.64; p < 0.05) and a fair-to-good discriminative ability (c-statistics range 0.74-0.84 for mortality and 0.59-0.69 for hospitalization). In HSD 34.2%, 10.9% and 3.8% were deemed mildly, moderately, and severely frail, respectively. In the SNAC-K cohort, the associations between PC-FI and mortality and hospitalization were stronger than in the HSD and PC-FI scores were associated with physical frailty (odds ratio 4.25 for each 0.1 increase; p < 0.05; area under the curve 0.84), poor physical performance, disability, injurious falls, and dementia. Almost 15% of primary care patients ≥ 60 years old are affected by moderate or severe frailty in Italy. We propose a reliable, automated, and easily implementable frailty index that can be used to screen the primary care population for frailty.

Prognostic significance of frailty status in patients with primary lung cancer

Lung cancer has one of the highest morbidity and mortality rates in the world. Frailty is common in many countries and is a major cause of premature functional decline and premature death in older adults, and may affect the treatment and prognosis of lung cancer patients. To investigate the predictive value of frailty at diagnosis on all-cause mortality in lung cancer patients, this study retrospectively collected and analysed clinical information on lung cancer patients from 2015-2018. A total of 1667 patients with primary lung cancer were finally included in this study. The median follow-up time of patients was 650 (493, 1001.5) days. A total of 297(17.8%) patients had FI-LAB(the frailty index based on laboratory test) status of frail at the moment of diagnosis and the all-cause mortality rate for all patients was 61.1% (1018/1667). In a univariate model, we found a higher total all-cause mortality risk in frail patients (frail vs. robust, HR(hazard ratio) = 1.616, 95% CI(confidence interval) = 1.349,1.936), after balancing other variables combined into model 1 to model 6. The results were analyzed visually using ROC(Receiver operating characteristic) curves with nomogram and the AUC values ranged from 0.866-0.874. The final inclusion of age, TNM stage, CCI(Charlson comorbidity index) score, surgery history and chemotherapy into a multifactorial model balanced the predictive power of frailty grading on all-cause mortality. The study showed that for lung cancer patients, the higher the level of frailty at diagnosis, the higher the risk of all-cause mortality. In the context of widespread electronic medical records in hospitals, it is convenient and feasible to use FI-LAB to assess the prognosis of lung cancer patients.

Wrist accelerometer temporal analysis as a prognostic tool for aged care residents: A sub‐study of the ReMInDAR trial

BACKGROUND

Objective measures for screening, prioritizing, and planning care for frail individuals are essential for appropriate aged care provision. This study evaluates metrics derived from actigraphy measures (captured by wrist accelerometer) as a digital biomarker to identify frail individuals at risk of adverse outcomes, including death, hospitalization, and cognitive decline.

METHODS

This was a secondary study using data from a randomized controlled trial assessing the effectiveness of an ongoing pharmacist service in residential aged care facilities. Three metrics are studied and compared: the Frailty Index, the daily time spent in light time activity, and the temporal correlation of the actigraphy signal, measured by detrended fluctuation analysis. The association between actigraphy-derived metrics at baseline and adverse events within 12 months (death, cognitive decline, and hospitalizations) was assessed using logistic regression.

RESULTS

Actigraphy records were available for 213 participants living in aged-care, median age of 85 years. Individuals with higher temporal correlation (activity is less random) were at lower risk of death (Standardized OR: 0.49; 95% CI 0.34, 0.7, p < 0.001) and hospitalization (Standardized OR: 0.57; 95% CI 0.42, 0.77, p < 0.001) in 12 months, but there was no difference in cognitive decline (Standardized OR: 1; 95% CI 0.74, 1.35, p = 0.98). The predictive model that included temporal correlation had an area under the curve of 0.70 (CI 0.60-0.80) for death and 0.64 (CI 0.54-0.72) for hospitalization.

CONCLUSION

Temporal correlation of the actigraphy signal from aged care residents was strongly associated with death and hospitalization, but not cognitive decline. Digital biomarkers may have a place as an objective, accurate, and low-cost patient metric to support risk stratification and clinical planning.

Validation of FES-I and Short FES-I Scales in the Polish Setting as the Research Tools of Choice to Identify the Fear of Falling in Older Adults

Fear of falling is associated with a clear hazard to individual self-reliance, reduced physical activity, as well as a sense of shame and loss of self-confidence. The present study aimed to complete the applicable translation and validation protocol for the Falls Efficacy Scale-International (FES-I) tool, following its prior adaptation to ensure full compatibility with the Polish setting. The FES-I questionnaire, along with its abridged version, was translated in line with the recommended standards of the MAPI Institute, taking into account both the cultural fabric and pertinent language specifics of the country. The survey was attended by 740 individuals (N = 740; 463 women, 277 men), over 60 years old. All respondents were required to complete both the FES-I and FES-I (Short) questionnaires twice, following an intervening period, and subsequently had their responses statistically assessed. The FES-I questionnaire, along with its abridged version, may be recommended as an effective assessment tool for addressing the fear of falling issue among the older adults, consequently allowing the teams of attending physicians, physiotherapists, psychologists, or psychiatrists to complete an unambiguous diagnosis, with a view to helping the patients overcome this particular type of anxiety.

Dynamics of multimorbidity and frailty, and their contribution to mortality, nursing home and home care need: A primary care cohort of 1 456 052 ageing people

BACKGROUND

Prevalence of both multimorbidity and frailty increases with age, but more evidence is needed to elucidate their relationship and their association with other health-related outcomes. We analysed the dynamics of both conditions as people age and calculate the associated risk of death, nursing home admission, and need for home care.

METHODS

Data were drawn from the primary care electronic health records of a longitudinal cohort of people aged 65 or older in Catalonia in 2010-2019. Frailty and multimorbidity were measured using validated instruments (eFRAGICAP, a cumulative deficit model; and SNAC-K, respectively), and their longitudinal evolution was described. Cox regression models accounted for the competing risk of death and adjusted by sex, socioeconomical status, and time-varying age, alcohol and smoking.

FINDINGS

We included 1 456 052 patients. Prevalence of multimorbidity was consistently high regardless of age, while frailty almost quadrupled from 65 to 99 years. Frailty worsened and also changed with age: up to 84 years, it was more related to concurrent diseases, and afterwards, to frailty-related deficits. While concurrent diseases contributed more to mortality, frailty-related deficits increased the risk of institutionalisation and the need for home care.

INTERPRETATION

The nature of people's multimorbidity and frailty vary with age, as does their impact on health status. People become frailer as they age, and their frailty is more characterised by disability and other symptoms than by diseases. Mortality is most associated with the number of comorbidities, whereas frailty-related deficits are associated with needing specialised care.

FUNDING

Instituto de Salud Carlos III through PI19/00535, and the PFIS Grant FI20/00040 (Co-funded by European Regional Development Fund/European Social Fund).

Beyond Chronological Age: A Multidimensional Approach to Survival Prediction in Older Adults

BACKGROUND

There is a growing interest in generating precise predictions of survival to improve the assessment of health and life-improving interventions. We aimed to (a) test if observable characteristics may provide a survival prediction independent of chronological age; (b) identify the most relevant predictors of survival; and (c) build a metric of multidimensional age.

METHODS

Data from 3 095 individuals aged ≥60 from the Swedish National Study on Aging and Care in Kungsholmen. Eighty-three variables covering 5 domains (diseases, risk factors, sociodemographics, functional status, and blood tests) were tested in penalized Cox regressions to predict 18-year mortality.

RESULTS

The best prediction of mortality at different follow-ups (area under the receiver operating characteristic curves [AUROCs] 0.878-0.909) was obtained when 15 variables from all 5 domains were tested simultaneously in a penalized Cox regression. Significant prediction improvements were observed when chronological age was included as a covariate for 15- but not for 5- and 10-year survival. When comparing individual domains, we find that a combination of functional characteristics (ie, gait speed, cognition) gave the most accurate prediction, with estimates similar to chronological age for 5- (AUROC 0.836) and 10-year (AUROC 0.830) survival. Finally, we built a multidimensional measure of age by regressing the predicted mortality risk on chronological age, which displayed a stronger correlation with time to death (R = -0.760) than chronological age (R = -0.660) and predicted mortality better than widely used geriatric indices.

CONCLUSIONS

Combining easily accessible characteristics can help in building highly accurate survival models and multidimensional age metrics with potentially broad geriatric and biomedical applications.

Systematic review of the utility of the frailty index and frailty phenotype to predict all-cause mortality in older people

BACKGROUND

Current guidelines for healthcare of community-dwelling older people advocate screening for frailty to predict adverse health outcomes, but there is no consensus on the optimum instrument to use in such settings. The objective of this systematic review of population studies was to compare the ability of the frailty index (FI) and frailty phenotype (FP) instruments to predict all-cause mortality in older people.

METHODS

Studies published before 27 July 2022 were identified using Ovid MEDLINE, Embase, Scopus, Web of Science and CINAHL databases. The eligibility criteria were population-based prospective studies of community-dwelling older adults (aged 65 years or older) and evaluation of both the FI and FP for prediction of all-cause mortality. The Scottish Intercollegiate Guidelines Network's Methodology checklist was used to assess study quality. The areas under the receiver operator characteristic curves (AUC) were compared, and the proportions of included studies that achieved acceptable discriminatory power (AUC>0.7) were calculated for each frailty instrument. The results were stratified by the use of continuous or categorical formats of each instrument. The review was reported in accordance with the PRISMA and SWiM guidelines.

RESULTS

Among 8 studies (range: 909 to 7713 participants), both FI and FP had comparable predictive power for all-cause mortality. The AUC values ranged from 0.66 to 0.84 for FI continuous, 0.60 to 0.80 for FI categorical, 0.63 to 0.80 for FP continuous and 0.57 to 0.79 for FP categorical. The proportion of studies achieving acceptable discriminatory power were 75%, 50%, 63%, and 50%, respectively. The predictive ability of each frailty instrument was unaltered by the number of included items.

CONCLUSIONS

Despite differences in their content, both the FI and FP instruments had modest but comparable ability to predict all-cause mortality. The use of continuous rather than categorical formats in either instrument enhanced their ability to predict all-cause mortality.

Utility of hospital frailty risk score for predicting postoperative outcomes in craniopharyngioma

OVERVIEW

Frailty is an age-associated decline in functional status leading to increased vulnerability to otherwise innocuous stressors. In neurosurgical patients, frailty has been associated with postoperative complications, increased mortality, longer hospitalization, and increased care costs for a variety of conditions. This study seeks to determine the association between frailty and postoperative outcomes in patients undergoing surgery for craniopharyngioma.

METHODS

The Nationwide Inpatient Sample (NIS) database was queried for patients diagnosed with craniopharyngioma who underwent surgery via either craniotomy or transsphenoidal approach. Comorbid diagnoses were used to calculate the Hospital Frailty Risk Score (HFRS) and assign patients to low (< 5), intermediate (5-15), or high-risk (> 15) categories. Logistic regression was completed to determine whether the HFRS category was predictive of mortality, postoperative complication, extended hospitalization, or increased hospital costs compared to age.

RESULTS

Increased frailty score was predictive of increased length of stay, increased hospital costs, and non-home discharge in binary logistic regression with good discrimination on the ROC curve compared to age at admission. HFRS risk categories were significantly predictive of the development of any complication, with 100% of high-risk patients developing a complication compared to 76% of intermediate-risk and 63% of low-risk patients. HFRS risk categories were also predictive of the extended length of stay (71%, 49%, and 11% for high-, intermediate-, and low-risk, respectively) and non-home discharge (86%, 56%, and 17%). Regression analysis was unable to be performed for mortality due to the low number of deaths in the study group.

CONCLUSION

In patients undergoing any surgery for craniopharyngioma, frailty is predictive of increased hospital length of stay and overall care costs. HFRS failed to independently predict mortality because the incidence of mortality is too low in this population to analyze. The HFRS is a valuable tool to identify post-operative outcomes following surgery for craniopharyngioma.

Physical performance measures in frailty screening: diagnostic and prognostic accuracy in the Toledo Study of Healthy Ageing

INTRODUCTION

The present study aimed to explore the diagnostic and prognostic accuracy of standard and population-specific Physical Performance Measures (PPMs) cut-off points for frailty screening.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

Population-based study including 2328 subjects from the Toledo Study of Healthy Aging (age = 76.37 ± 6.78). Data related to frailty status and PPMs was collected at baseline visit (2011-2013). Mortality and hospitalization were ascertained up to March 2019 and December 2017, respectively, whereas disability onset and worsening were evaluated in the 2015-2017 visit.

METHODS

Gait speed and Short Physical Performance Battery population-specific cut-off points for frailty were computed using receiver operating characteristics (ROC) curve analysis. Head-to-head comparison of associations with adverse events against existing reference values (SPPB≤6, GS < 0.8 m/s) and classical (Frailty Phenotype, Frailty Index) and newly incorporated frailty tools (12- and 5-item Frailty Trait Scale) were explored through logistic and Cox regressions. Predictive ability was compared through areas under the curves (AUCs) for disability onset/worsening and integrated AUCs for mortality and hospitalization (time-censoring adverse events).

RESULTS

PPMs population-specific cut-off points (SPPB ≤7 and GS ≤ 0.75 m/s for males; SPPB ≤4 and GS ≤ 0.5 for females) outperformed published reference thresholds in terms of diagnostic accuracy. Frailty identified through PPMs was associated with adverse events (death, hospitalization and incident disability) similarly to that assessed using the newly incorporated tools and showed similar prognostic accuracy (mortality [IAUCs≈0.7], hospitalization [IAUCs≈0.8] and disability onset/worsening [AUCs≈0.62]), except for the tool used to assess frailty.

CONCLUSIONS

Our results suggest that PPMs might serve as the first screen to identify candidates for further frailty assessment and exploration of underlying mechanisms, allowing opportunistic on-time screening in different settings (community and primary care) in which frailty instruments are rarely implementable.

Conceptualizing Biological Aging and Frailty in Orthopaedics: A Framework for Clinical Practice

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Biological aging can best be conceptualized clinically as a combination of 3 components: frailty, comorbidity, and disability.

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Despite advancements in the understanding of senescence, chronological age remains the best estimate of biological age. However, a useful exercise for practitioners is to look beyond chronological age in clinical and surgical decision-making.

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A chronologically aging person does not age biologically at the same rate.

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The best way to understand frailty is to consider it as a physical phenotype.

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Physical optimization should parallel medical optimization before elective surgery.

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The poorer the host (both in terms of bone quality and propensity for healing), the more robust the implant construct must be to minimize reliance on host biology.

Association Between Physical Functioning and Time Until a New Hospitalization in Community-Dwelling Older Adults: A Prospective Cohort Study

BACKGROUND AND PURPOSE

Physical functioning refers to the ability to independently perform activities that require physical ability, and may be an important tool for predicting a higher risk of hospitalization. The objective of this study was to verify whether aspects of physical functioning are independently associated with the risk for new hospitalization in older adults seen in primary health care.

METHODS

This prospective cohort study consisted of 473 older adults 60 years and older who had not been hospitalized in the prior year. Hospitalization records were obtained with authorization from the hospital admission. Depending on physical functioning, the probability of a new hospital admission within the next 5 years was determined based on survival analysis and the Kaplan-Meier curve. Physical functioning was evaluated using 5 easy-to-administer tests: handgrip strength using a Jamar dynamometer, functional performance using the Short Physical Performance Battery, balance using the step test, mobility using the Timed Up and Go (TUG) test, and gait speed using the 4-m walk test. The association between poor physical functioning and new hospitalization was verified using a Cox regression model, adjusted for sex, age, number of comorbidities, number of medications, and BMI. Models were implemented separately for each physical functioning test.

RESULTS

In the sample, 32% had been hospitalized at least once in 5 years. The Kaplan-Meier curve showed a decrease in the probability of nonhospitalization within the next 5 years. Cox regression analysis showed an association between hospitalization within the next 5 years and mobility on the TUG test of more than 12.4 seconds in the crude (hazard ratio [HR] = 1.33, 95% CI = 1.10-1.60) and adjusted models (HR = 1.26, 95% CI = 1.02-1.56), and balance using the step test of more than 7.5 seconds in the crude (HR = 1.27, 95% CI = 1.03-1.56) model.

CONCLUSIONS

Physical functioning tests demonstrated that poor physical performance predicts new hospitalization, and reinforced the importance of their application in physical therapy practice in primary health care settings.

Predictive Validity of Motor Fitness and Flexibility Tests in Adults and Older Adults: A Systematic Review

Motor fitness and flexibility have been linked to several health issues. We aimed to investigate the predictive validity of motor fitness and flexibility tests in relation to health outcomes in adults and older adults. Web of Science and PubMed databases were screened for studies published from inception to November 2020. Two authors systematically searched, evaluated, and extracted data from identified original studies and systematic reviews/meta-analysis. Three levels of evidence were constructed: strong, moderate, and limited/inconclusive evidence. In total, 1182 studies were identified, and 70 studies and 6 systematic reviews/meta-analysis were summarized. Strong evidence indicated that (i) slower gait speed predicts falls and institutionalization/hospitalization in adults over 60 years old, cognitive decline/impairment over 55 years old, mobility disability over 50 years old, disability in instrumental activities of daily living (IADL) over 54 years old, cardiovascular disease risk over 45 years old, and all-cause mortality over 35 years old; (ii) impaired balance predicts falls and disability in IADL/mobility disability in adults over 40 years old and all-cause mortality over 53 years old; (iii) worse timed up&go test (TUG) predicts falls and fear of falling over 40 years old. Evidence supports that slower gait speed, impaired balance, and worse TUG performance are significantly associated with an increased risk of adverse health outcomes in adults.

A quantile frailty index without dichotomization

measures of health quantify the aging process of individuals. They should be interpretable, associated with future adverse outcomes, and straightforward to assemble. We use the rank-ordering of risk within a population to construct a quantile frailty index (QFI) that avoids dichotomization, is convenient and interpretable, and is associated with adverse outcomes. We show that the QFI outperforms previous frailty index (FI) measures on cross-sectional laboratory data (NHANES, CSHA, and ELSA). We construct the QFI by ranking the risk of individuals with respect to a reference population. Sex-specific reference populations narrow male-female FI differences as a function of age, and improve predictive performance. With a fixed reference population of 80-85 year olds, our QFI appears similar to earlier FI measures. With an age-matched reference population for each individual, we obtain a QFI that contains very little age information and that has similar predictive performance as other age-controlled FI measures. Adding age as an auxiliary variable leads to significantly better performance. We conclude that age should be controlled for when evaluating the predictive performance of summary measures of health. This is straight-forward to do with the QFI.

Health trajectories after age 60: the role of individual behaviors and the social context

Background: This study aimed to detect health trajectories after age 60, and to explore to what extent individual and social factors may contribute to healthier aging.

Methods: Twelve-year health trajectories were identified in subjects from the Swedish National Study on Aging and Care in Kungsholmen (N=3108), integrating five indicators of disease, physical and cognitive function, and disability through nominal response models. Growth mixture models were applied to explore health trajectories in terms of rate and pattern of change. Baseline information about health-related behaviors and the social context was collected through standardized questionnaires. The strength of the associations was estimated using logistic regression, and their impact through population attributable fractions (PAF).

Results: Three trajectories were identified grouping 78%, 18%, and 4% of people with respectively increasing rates of health decline. Compared to the best trajectory, subjects in the middle and worst trajectories became functionally dependent 12.0 (95% CI: 11.4-12.6) and 12.1 (95% CI: 11.5-12.7) years earlier, respectively. Insufficient physical activity (OR: 3.38, 95% CI: 2.58-4.42), financial strain (OR: 2.76, 95% CI: 1.77-4.30), <12 years education (OR: 1.53, 95% CI: 1.14-2.04), low social connections (OR: 1.45, 95% CI: 1.09-1.94), low social participation (OR: 1.39, 95% CI: 1.06-1.83) and a body mass index ≥25 (OR: 1.34, 95% CI: 1.03-1.75) were associated with belonging to the middle/worst trajectories. The highest PAFs were observed for insufficient physical activity (27.1%), low education (19.3%) and low social participation (15.9%); a total PAF of 66.1% was obtained.

Conclusions: Addressing the social determinants of health in its broadest sense, complementarily considering life-long factors belonging to the socioeconomic, psychosocial, and behavioral dimensions, should be central to any strategy aimed at fostering health in older age.

Fostering healthy aging: The interdependency of infections, immunity and frailty

Untangling the interdependency of infections, immunity and frailty may help to clarify their roles in the maintenance of health in aging individuals, and the recent COVID-19 pandemic has further highlighted such priority. In this scoping review we aimed to systematically collect the evidence on 1) the impact of common infections such as influenza, pneumonia and varicella zoster on frailty development, and 2) the role played by frailty in the response to immunization of older adults. Findings are discussed under a unifying framework to identify knowledge gaps and outline their clinical and public health implications to foster a healthier aging. Twenty-nine studies (113,863 participants) selected to answer the first question provided a moderately strong evidence of an association between infections and physical as well as cognitive decline - two essential dimensions of frailty. Thirteen studies (34,520 participants) investigating the second aim, showed that frailty was associated with an impaired immune response in older ages, likely due to immunosenescence. However, the paucity of studies, the absence of tools to predict vaccine efficacy, and the lack of studies investigating the efficacy of newer vaccines in presence of frailty, strongly limit the formulation of more personalized immunization strategies for older adults. The current evidence suggests that infections and frailty repeatedly cross each other pathophysiological paths and accelerate the aging process in a vicious circle. Such evidence opens to several considerations. First, the prevention of both conditions pass through a life course approach, which includes several individual and societal aspects. Second, the maintenance of a well-functioning immune system may be accomplished by preventing frailty, and vice versa. Third, increasing the adherence to immunization may delay the onset of frailty and maintain the immune system homeostasis, beyond preventing infections.

The Functional Continuum Scale in Relation to Hospitalization Density in Older Adults: The FRADEA Study

BACKGROUND

There is a need to know the relationship between function and hospitalization risk in older adults. We aimed at investigating whether the Functional Continuum Scale (FCS), based on basic (BADL) and instrumental (IADL) activities of daily living and frailty, is associated with hospitalization density in older adults across 12 years of follow-up.

METHODS

Cohort study, with a follow-up of 12 years. A total of 915 participants aged 70 years and older from the Frailty and Dependence in Albacete (FRADEA) study, a population-based study in Spain, were included. At baseline, the FCS, sociodemographic characteristics, comorbidity, number of medications, and place of residence were assessed. Associations with first hospitalization, number of hospitalizations, and 12-year density of hospitalizations were assessed using Kaplan-Meier curves, Poisson regression analyses, and density models.

RESULTS

The median time until the first hospitalization was shorter toward the less functionally independent end of the FCS, from 3917 days (95% confidence interval [CI] 3701-3995) to 1056 days (95% CI 785-1645) (p < .001). The incidence rate ratio (IRR) for all hospitalizations increased from the robust category until the frail one (IRR 1.89), and thereafter it decreased until the worse functional category. Those who were BADL dependent presented an increased hospitalization density in the first 4 follow-up years (58%), those who were frail in the third-to-sixth follow-up years (55%), while in those prefrail or robust the hospitalization density was homogeneous during the complete follow-up.

CONCLUSIONS

The FCS is useful for stratifying the risk of hospitalization and for predicting the density of hospitalizations in older adults.

Why data on frailty and SARS-CoV-2 infection are basic to progress

Several studies showed that frailty was a predictor of in-hospital death in older adults with COVID-19. The mechanisms through which frailty increases the severity of COVID-19 are several, including immunosenescense and dysregulated inflammation. Whether individuals affected by frailty exhibit a higher susceptibility to SARS-CoV-2 infection remains an open question. Here we report the case series of 40 older persons that in February 2020, before the first case of COVID-19 was detected in Italy, went together on a winter holiday. Back home, 7 of them developed influenza-like symptoms and one was hospitalized due to COVID-19 pneumonia. Between May and July, the seniors were offered the possibility to be tested for SARS-CoV-2 antibody positivity. Twenty-seven of them accepted: 13 had a positive serological test whereas no active infection was found. Comparing the characteristics of those who tested positive and the others, we found that the former group was frailer, exhibiting higher Clinical Frailty Scale scores.

Beyond Chronological Age: Frailty and Multimorbidity Predict In-Hospital Mortality in Patients With Coronavirus Disease 2019

BACKGROUND

We evaluated whether frailty and multimorbidity predict in-hospital mortality in patients with COVID-19 beyond chronological age.

METHOD

A total of 165 patients admitted from March 8th to April 17th, 2020, with COVID-19 in an acute geriatric ward in Italy were included. Predisease frailty was assessed with the Clinical Frailty Scale (CFS). Multimorbidity was defined as the co-occurrence of ≥2 diseases in the same patient. The hazard ratio (HR) of in-hospital mortality as a function of CFS score and number of chronic diseases in the whole population and in those aged 70+ years were calculated.

RESULTS

Among the 165 patients, 112 were discharged, 11 were transferred to intensive care units, and 42 died. Patients who died were older (81.0 vs 65.2 years, p < .001), more frequently multimorbid (97.6 vs 52.8%; p < .001), and more likely frail (37.5 vs 4.1%; p < .001). Less than 2.0% of patients without multimorbidity and frailty, 28% of those with multimorbidity only, and 75% of those with both multimorbidity and frailty died. Each unitary increment in the CFS was associated with a higher risk of in-hospital death in the whole sample (HR = 1.3; 95% CI = 1.05-1.62) and in patients aged 70+ years (HR = 1.29; 95% CI = 1.04-1.62), whereas the number of chronic diseases was not significantly associated with higher risk of death. The CFS addition to age and sex increased mortality prediction by 9.4% in those aged 70+ years.

CONCLUSIONS

Frailty identifies patients with COVID-19 at risk of in-hospital death independently of age. Multimorbidity contributes to prognosis because of the very low probability of death in its absence.

Course of frailty stratified by physical and mental multimorbidity patterns: a 5-year follow-up of 92,640 participants of the LifeLines cohort study

BACKGROUND

The frailty index (FI) is a well-recognized measurement for risk stratification in older people. Among middle-aged and older people, we examined the prospective association between the FI and mortality as well as its course over time in relation to multimorbidity and specific disease clusters.

METHODS

A frailty index (FI) was constructed based on either 64 (baseline only) or 35 health deficits (baseline and follow-up) among people aged ≥ 40 years who participated in LifeLines, a prospective population-based cohort living in the Northern Netherlands. Among 92,640 participants, multivariable Cox proportional hazard models were fitted to study the hazard ratio (HR) of the FI at baseline, as well as for 10 chronic disease clusters for all-cause mortality over a 10-year follow-up. Among 55,426 participants, linear regression analyses were applied to study the impact of multimorbidity and of specific chronic disease clusters (independent variables) on the change of frailty over a 5-year follow-up, adjusted for demographic and lifestyle characteristics.

RESULTS

The FI predicted mortality independent of multimorbidity and specific disease clusters, with the highest impact in people with either endocrine, lung, or heart diseases. Adjusted for demographic and lifestyle characteristics, all chronic disease clusters remained independently associated with an accelerated increase of frailty over time.

CONCLUSIONS

Frailty may be seen as a final common pathway for premature death due to chronic diseases. Our results suggest that initiating frailty prevention at middle age, when the first chronic diseases emerge, might be relevant from a public health perspective.

Physical performance measures and hospital outcomes among Italian older adults: results from the CRIME project

BACKGROUND

Older adults are a complex population, at risk of adverse events during and after hospital stay.

AIM

To investigate the association of walking speed (WS) and grip strength (GS) with adverse outcomes, during and after hospitalization, among older individuals admitted to acute care wards.

METHODS

Multicentre observational study including 1123 adults aged ≥ 65 years admitted to acute wards in Italy. WS and GS were measured at admission and discharge. Outcomes were length-of-stay, in-hospital mortality, 1-year mortality and rehospitalisation. Length-of-stay was defined as a number of days from admission to discharge/death.

RESULTS

Mean age was 81 ± 7 years, 56% were women. Compared to patients with WS ≥ 0.8 m/sec, those unable to perform or with WS < 0.8 m/sec had a higher likelihood of longer length-of-stay (OR 2.57; 95% CI 1.63-4.03 and 2.42; 95% CI 1.55-3.79) and 1-year mortality and rehospitalization (OR 1.47, 95% CI 1.07-2.01; OR 1.57, 95% CI 1.04-2.37); those unable to perform WS had a higher likelihood of in-hospital mortality (OR 9.59; 95% CI 1.23-14.57) and 1-year mortality (OR 2.60; 95% CI 1.37-4.93). Compared to good GS performers, those unable to perform had a higher likelihood of in-hospital mortality (OR 17.43; 95% CI 3.87-28.46), 1-year mortality ( OR 3.14; 95% CI 1.37-4.93) and combination of 1-year mortality and rehospitalisation (OR 1.46; 95% CI 1.01-2.12); poor GS performers had a higher likelihood of 1-year mortality (OR 1.39; 95% CI 1.03-2.35); participants unable to perform GS had a lower likelihood of rehospitalisation (OR 0.59; 95% CI 0.39-0.89).

CONCLUSION

Walking speed (WS) and grip strength (GS) are easy-to-assess predictors of length-of-stay, in-hospital and post-discharge death and should be incorporated in the standard assessment of hospitalized patients.

Cognitive and physical markers of prodromal dementia: A 12-year-long population study

INTRODUCTION

The aim is to test whether adding a simple physical test such as walking speed (WS) to the neuropsychological assessment increases the predictive ability to detect dementia.

METHODS

The 2546 dementia-free people from the SNAC-K study were grouped into four profiles: (1) healthy profile; (2) isolated cognitive impairment, no dementia (CIND, scoring 1.5 standard deviation below age-specific means on ≥1 cognitive domains); (3) isolated slow WS (<0.8 m/s); (4) CIND+ slow WS. The hazard of dementia (Cox regression), the positive and negative predictive values (PPV, NPV), and the area under the curve (AUC) were estimated.

RESULTS

Participants with CIND +slow WS demonstrated the highest hazard of dementia (3.4; 95% confidence interval [CI]: 2.5-4.8). The AUC increased from 0.69 for isolated CIND to 0.83 for CIND+ slow WS. Such an increase was due to the improvement of the PPV, the NPV remaining optimal.

DISCUSSION

Adding WS to the cognitive assessment dramatically increases the diagnostic accuracy of prodromal dementia.

Using a genetic algorithm to derive a highly predictive and context-specific frailty index

The frailty index (FI) is one of the most widespread tools used to predict poor, health-related outcomes in older persons. The selection of clinical and functional deficits to include in a FI is mostly based on the users’ clinical experience. However, this approach may not be sufficiently accurate to predict health outcomes in particular subgroups of individuals. In this study, we implemented an optimization algorithm, the genetic algorithm, to create a highly performant (FI) based on our prediction goals, rather than on a predetermined clinical selection of deficits, using data from the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K) and 109 potential deficits identified in the dataset. The algorithm was personalized to obtain a FI with high discrimination ability in the prediction of mortality. The resulting FI included 40 deficits and showed areas under the curve consistently higher than 0.80 (range 0.81-0.90) in the prediction of 3-year and 6-year mortality in the whole sample and in sex and age subgroups. This methodology represents a promising opportunity to optimize the exploitation of medical and administrative databases in the construction of clinically relevant frailty indices.

Safety of Major Abdominal Operations in the Elderly: A Study of Geriatric-Specific Determinants of Health

BACKGROUND

Preoperative assessment of geriatric-specific determinants of health may enhance perioperative risk stratification among elderly patients. This study examines effects of geriatric-specific variables on postoperative outcomes in patients undergoing elective major abdominal operations.

METHODS

Patients included in the ACS NSQIP pilot Geriatric Surgery Research File program who underwent elective pancreatic, liver, and colorectal operations between 2014 and 2016 were examined. Multivariable analyses were performed to evaluate associations between patient-specific geriatric variables and risk of death, morbidity, readmission, and discharge destination.

RESULTS

A total of 4165 patients were included. Patients ≥85 years were more likely to die, experience postoperative morbidity, and be discharged to a facility (all p ≤ 0.039) than younger patients. Preoperatively, patients ≥85 years were more likely to use a mobility aid, have a prior fall, have consent signed by a surrogate, and to live alone at home prior to operation (all p < 0.001). After adjustment for ACS NSQIP-estimated probabilities of morbidity or mortality, no geriatric-specific preoperative risk factors were significantly associated with increased risk of death or complications in any age group (all p > 0.055). Patients 75-84 and ≥85 years were more likely to be discharged to facility (OR 2.33 and 4.75, respectively, both p < 0.001) compared to patients 65-74 years. All geriatric-specific variables: use of mobility aid, living alone, consent signed by a surrogate, and fall history, were significantly associated with discharge to a facility (all p ≤ 0.001).

CONCLUSIONS

After adjusting for comorbid conditions, geriatric-specific variables are not associated with postoperative mortality and morbidity among elderly patients; however, geriatric-specific variables are significantly associated with discharge to a facility.