The accumulation of deficits approach to describe frailty

Update on Perioperative Delirium

A strong association between frailty and in-hospital delirium in nonsurgical patients has been shown. Physical and cognitive frailties have been associated with decline and dysfunction in the frontal cognitive domains. Risk factors for frailty are similar to risk factors for postoperative delirium (POD). Frailty can be screened and diagnosed by various tools and instruments. Different anesthetic techniques have been studied to decrease the incidence of POD. However, no anesthetic technique has been conclusively proven to decrease the risk of POD. Patients with dementia develop delirium more often, and delirium is associated with accelerated cognitive decline.

Physiological aging in India: The role of the epidemiological transition

We construct a cohort-based frailty index from age-related health deficits to investigate physiological aging in India over the period 1990-2019. During this period, the Indian states underwent at different speeds the epidemiological transition and experienced unprecedented economic growth. We show that the rate of physiological aging remained remarkably stable to the changing environment. Age-related health deficits increased by about 3 percent per year of age with little variation across states, ages, cohorts, and over time. We find that, with advancing epidemiological transition, health deficits for given age declined at the individual level (within states and within cohorts). Across cohorts born between 1900 and 1995, we show that, for given age, health deficits are higher for later-born cohorts until birth years around 1940 and remained trendless afterwards. We propose a selection-based theory of aging during the epidemiological transition that explains these facts.

Frailty in Kingdom of Saudi Arabia-Prevalence and Management, Where Are We?

A recent report from the United Nations state that the percentage of elderly individuals in the Kingdom of Saudi Arabia (KSA) will witness a sharp increase in the next three decades (5.6% in 2017 to 23% by 2050). This situation will lead to an increased prevalence of comorbidities and hence, will require close monitoring and constant care of such individuals who are prone to suffer from complications such as arthritis, cardiovascular disorders, diabetes, neurological disorders, etc. Frailty is one such age-related phenomenon which enhances the risk of falling, functional restrictions and greater vulnerability to adverse consequences, which tend to lead to institutionalization. Such factors highlight the importance of the urgent awareness for circumventing the progression of frailty toward a compromised health status. This concise report is an attempt to sum up the relevant research articles published with regard to frailty and concomitant diseases in the last 5 years. It also sums up the research on frailty in the KSA elderly population, till date. This article reflects the opinions of an author on tackling such issues through a well-directed mechanism involving interdisciplinary transitional care and geriatric co-management.

Development of a frailty index from the Dutch public health monitor 2016 and investigation of its psychometric properties: a cross-sectional study

BACKGROUND

Frailty in older adults is an increasing challenge for individuals, health care organizations and public health, both globally and in The Netherlands. To focus on frailty prevention from a public health perspective, understanding of frailty status is needed. To enable measurement of frailty within a health survey that currently does not contain an established frailty instrument, we aimed to construct a frailty index (FI) and investigate its psychometric properties.

METHODS

We conducted a cross-sectional study using data from the Dutch Public Health Monitor (DPHM), including respondents aged ≥ 65 years (n = 233,498). Forty-two health deficits were selected based on literature, previously constructed FIs, face validity and standard criteria for FI construction. Deficits were first explored by calculating Cronbach's alpha, point-polyserial correlations, and factor loadings. Thereafter, we used the Graded Response Model (GRM) to assess item difficulty, item discrimination, and category thresholds.

RESULTS

Cronbach's alpha for the 42 items was 0.91. Thirty-seven deficits showed strong psychometric properties: they scored above the cutoff values for point-polyserial correlations (0.3) or factor loadings (0.4) and had moderate to very high discrimination parameters (≥ 0.65). These deficits were retained in the scale. Retaining the deficits with favorable measurement properties and removing the remaining deficits resulted in the FI-HM37.

CONCLUSION

The FI-HM37 was developed, an FI with 37 deficits indicative of frailty, both statistically and conceptually. Our results indicate that health monitors can be used to measure frailty, even though they were not directly designed to do so. The GRM is a suitable approach for deficit selection, resulting in a psychometrically strong scale, that facilitates assessment of frailty levels using the DPHM.

Associations among frailty and quality of life in older patients with cancer treated with chemotherapy

INTRODUCTION

Previous studies have suggested that frailty among older adults with cancer is associated with a variety of negative outcomes, including greater chemotherapy toxicity and worse survival. However, results often do not include patient-reported outcomes, such as quality of life (QOL). The objective of this study was to evaluate frailty prior to receipt of moderately- or highly-emetogenic chemotherapy and acute changes in QOL in patients at least 65 years of age. It was hypothesized that frail patients would report greater declines in QOL.

MATERIALS AND METHODS

Participants completed questionnaires before receiving their first infusion and again five days later. A 59-item deficit accumulation index score was created at baseline using a modified Rockwood frailty index. QOL was assessed using the Functional Assessment of Cancer Therapy-General (FACT-G). The relationship between baseline frailty and QOL was evaluated using a dichotomized deficit accumulation index (frail vs. robust) in repeated measures ANOVA.

RESULTS

Study participants (n = 151) had a mean age of 72 (SD = 4.5) and 62% were female. Nearly half (42%) were frail at baseline. Frail participants reported worse QOL at baseline compared to robust participants. Frail patients reported smaller declines in overall and physical (p < 0.0001) and emotional (p = 0.006) QOL from baseline to five days after receiving chemotherapy. At five days, frail participants reported better emotional and physical QOL compared to robust participants.

DISCUSSION

Contrary to expectations, frail patients reported smaller declines in QOL compared to robust patients using a deficit accumulation index. These results can be used to help educate frail patients on what to expect during treatment.

Heath status, frailty, and multimorbidity in patients with emergency general surgery conditions

BACKGROUND

Although nearly 1 million older adults are admitted for emergency general surgery conditions yearly, the extent to which baseline health influences the development and treatment of emergency general surgery conditions is unknown. We evaluated baseline health and older patients with and without emergency general surgery conditions.

METHODS

We used the prospectively collected Medicare Current Beneficiary Survey with Medicare claims and 2 validated health frameworks: (1) Deficit Accumulation Frailty Score and (2) Complex Multimorbidity. Self-reported health and function items were used to derive pre-emergency general surgery conditions Deficit Accumulation Frailty Score and Complex Multimorbidity scores. Deficit Accumulation Frailty Score ranges from 0 (no frailty deficits) to 100 (all possible deficits present). Complex Multimorbidity is a 3-point categorical rank based on the presence of chronic conditions, functional limitations, and geriatric syndromes. Specific survey factors were also examined to determine association with development of emergency general surgery conditions or use of operative management.

RESULTS

Of 54,417 individuals, 1,960 had emergency general surgery conditions (median age 79 [interquartile range 73-84]). Patients with emergency general surgery conditions had significantly higher Deficit Accumulation Frailty Score (19 [interquartile range 11-31] vs 14 [8-24]) and were more likely to be in the most severe Complex Multimorbidity category (38% vs 29%). Emergency general surgery conditions patients had higher proportions of nearly every health category, with the most striking differences in functional limitations. Patients who were treated nonoperatively had the poorest overall baseline health.

CONCLUSION

Patients who developed emergency general surgery conditions had more severe health burden than patients who did not, particularly in functional status. Clinicians must better understand the interaction between baseline health vulnerability and emergency surgical disease to improve prognostication and ensure alignment of patient goals and treatment strategies.

Physiological aging around the World

We extract data on physiological aging by computing a frailty index for 201 countries over the period 1990–2019. Using panel estimation techniques, we show that the macro frailty index replicates basic regularities previously observed in related studies of aging at the individual level. We then use the frailty index to highlight trends of global physiological aging and its relationship to economic growth. Holding population age structure fixed, the global frailty index has on average increased by about 2 percent over the last 30 years. The average person has therefore aged by what corresponds to about one life-year of physiological aging. This overall trend is relatively similar across different geographical regions. We also document a negative relationship between physiological aging of the workforce and economic growth. According to our preferred specification, a one percent increase in the frailty index of the workforce is associated with a 1.5 percent decline of GDP per capita. This means that average annual growth of labor productivity would have been 0.1 percentage points higher without physiological aging in the period 1990-2019.

Metastatic Colorectal Cancer Outcomes by Age Among ARCAD First- and Second-Line Clinical Trials

BACKGROUND

We evaluated the time to progression (TTP) and survival outcomes of second-line therapy for metastatic colorectal cancer among adults aged 70 years and older compared with younger adults following progression on first-line clinical trials.

METHODS

Associations between clinical and disease characteristics, time to initial progression, and rate of receipt of second-line therapy were evaluated. TTP and overall survival (OS) were compared between older and younger adults in first- and second-line trials by Cox regression, adjusting for age, sex, Eastern Cooperative Oncology Group Performance Status, number of metastatic sites and presence of metastasis in the lung, liver, or peritoneum. All statistical tests were 2-sided.

RESULTS

Older adults comprised 16.4% of patients on first-line trials (870 total older adults aged >70 years; 4419 total younger adults aged ≤70 years, on first-line trials). Older adults and those with Eastern Cooperative Oncology Group Performance Status >0 were less likely to receive second-line therapy than younger adults. Odds of receiving second-line therapy decreased by 11% for each additional decade of life in multivariable analysis (odds ratio = 1.11, 95% confidence interval = 1.02 to 1.21, P = .01). Older and younger adults enrolled in second-line trials experienced similar median TTP and median OS (median TTP = 5.1 vs 5.2 months, respectively; median OS = 11.6 vs 12.4 months, respectively).

CONCLUSIONS

Older adults were less likely to receive second-line therapy for metastatic colorectal cancer, though we did not observe a statistical difference in survival outcomes vs younger adults following second-line therapy. Further study should examine factors affecting decisions to treat older adults with second-line therapy. Inclusion of geriatric assessment may provide better criteria regarding the risks and benefits of second-line therapy.

Social vulnerability and aging of elderly people in the United States

We use 7 waves of the Health and Retirement Study and construct a social vulnerability index (SVI) for elderly U.S. Americans (born 1913–1966). We show that the SVI is mildly larger for men than for women and increases in age from above age 60 onwards for both genders. Social vulnerability of men (but not of women) is lower in the West and Midwest than in other regions and higher income mildly reduces the SVI for men (but not for women). In cohort analysis we find an increase of the SVI for individuals born in the late 1940s or later, which is, however, statistically significant only for women. In order to investigate the nexus between social vulnerability and aging, we construct a frailty index from the same data. We find that socially vulnerable persons display more health deficits at any age. Using the initial SVI (at first interview) we find that social vulnerability exerts a significant impact on subsequent accumulation of health deficits, which is of about the same size for men and women. A one standard deviation increase in the initial SVI leads to a 20 percent increase of the frailty index at any age.

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Panel study of social vulnerability and aging in the U.S.

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Social vulnerability index (SVI) increases for women born after 1940.

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Strong impact of initial SVI on subsequent accumulation of health deficits.

Longevity leap: mind the healthspan gap

Life expectancy has increased by three decades since the mid-twentieth century. Parallel healthspan expansion has however not followed, largely impeded by the pandemic of chronic diseases afflicting a growing older population. The lag in quality of life is a recognized challenge that calls for prioritization of disease-free longevity. Contemporary communal, clinical and research trends aspiring to extend the health horizon are here outlined in the context of an evolving epidemiology. A shared action integrating public and societal endeavors with emerging interventions that target age-related multimorbidity and frailty is needed. A multidimensional buildout of a curative perspective, boosted by modern anti-senescent and regenerative technology with augmented decision making, would require dedicated resources and cost-effective validation to responsibly bridge the healthspan-lifespan gap for a future of equitable global wellbeing.

The Importance of Age in the Prediction of Mortality by a Frailty Index: A Machine Learning Approach in the Irish Longitudinal Study on Ageing

The quantification of biological age in humans is an important scientific endeavor in the face of ageing populations. The frailty index (FI) methodology is based on the accumulation of health deficits and captures variations in health status within individuals of the same age. The aims of this study were to assess whether the addition of age to an FI improves its mortality prediction and whether the associations of the individual FI items differ in strength. We utilized data from The Irish Longitudinal Study on Ageing to conduct, by sex, machine learning analyses of the ability of a 32-item FI to predict 8-year mortality in 8174 wave 1 participants aged 50 or more years. By wave 5, 559 men and 492 women had died. In the absence of age, the FI was an acceptable predictor of mortality with AUCs of 0.7. When age was included, AUCs improved to 0.8 in men and 0.9 in women. After age, deficits related to physical function and self-rated health tended to have higher importance scores. Not all FI variables seemed equally relevant to predict mortality, and age was by far the most relevant feature. Chronological age should remain an important consideration when interpreting the prognostic significance of an FI.

Validation of a Deficit-Accumulation Frailty Index in the ASPirin in Reducing Events in the Elderly Study and Its Predictive Capacity for Disability-Free Survival

Frailty is a state of heightened vulnerability and susceptibility to physiologic stressors that increases with age. It has shown increasing utility in predicting a range of adverse health outcomes. Here, we characterize a 67-item deficit-accumulation frailty index (FI) in 19 110 community-dwelling individuals in the ASPirin in Reducing Events in the Elderly clinical trial. Participants aged 65-98 years were recruited from the United States and Australia and were without diagnosed dementia and cardiovascular disease, and major physical disability. The median FI score was .10 (interquartile range: .07-.14) at baseline, and the prevalence of frailty (FI > .21) increased from 8.1% to 17.4% after 6 years. FI was positively associated with age, and women had significantly higher scores than men at all ages. The FI was negatively correlated with gait speed (r = -.31) and grip strength (r = -.46), and strongly associated with a modified Fried's frailty phenotype (p < .0001, for all comparisons). Frailty was associated with the primary composite outcome capturing independent life lived free of major disability and dementia, and increased the rate of persistent physical disability (hazard ratio: 21.3, 95% confidence interval: 15.6-28.9). It added significantly to the predictive capacity of these outcomes above age, sex, and ethnicity alone. The FI is thus a useful biomarker of aging even among relatively healthy older individuals and provides important information about an individual's vulnerability to and risk of disease.

Sleep duration and incident frailty: The Rural Frailty Study

Background

The association between sleep duration and frailty remains unconclusive since most of the studies have been cross-sectional. Therefore, this study aimed to analyze the association between sleep duration, sleep complaints, and incident frailty.

Methods

A community-based cohort study from rural areas in Mexico with 309 older adults aged 70 and over. Data from waves two and three of the Rural Frailty Study were used. We operationalized the Fried frailty phenotype to describe prevalent and incident frailty at two consecutive waves. Sleep duration was classified as: ≤ 5 h, 6 h, 7–8 h, and ≥ 9 h; and the self-reported sleep complaints as a dichotomous variable. Analyses were performed using Poison regression models.

Results

The average age was 76.2 years and 55.3% were women; the incidence of frailty was 30.4%; 13.3% slept ≤5 h, and 38.5% ≥ 9 h. Compared with the group that slept 7–8 h, the risk of frailty at 4.4 years of follow-up was significantly higher among those who slept ≤5 h (adjusted RR 1.80, 95% CI: 1.04–3.11) and among those who slept ≥9 h (adjusted RR 1.69, 95% CI: 1.10–2.58). Sleep complaints were not associated with incident frailty (adjusted RR 1.41, 95% CI: 0.94–2.12).

Conclusions

Our results show that short and long sleep duration are associated with the incidence of frailty. Studies that objectively evaluate sleep duration are needed to clarify whether meeting the recommended hours of sleep decreases frailty incidence.

The impact of interventions on management of frailty in hospitalized frail older adults: a systematic review and meta-analysis

BACKGROUND

One of the most challenging issues for the elderly population is the clinical state of frailty. Frailty is defined as a cumulative decline across psychological, physical, and social functioning. Hospitalization is one of the most stressful events for older people who are becoming frail. The aim of the present study was to determine the effectiveness of interventions focused on management of frailty in hospitalized frail older adults.

METHODS

A systematic review and meta-analysis of research was conducted using the Medline, Embase, Cochrane, ProQuest, CINAHL, SCOPUS and Web of Science electronic databases for papers published between 2000 and 2019. Randomized controlled studies were included that were aimed at the management of frailty in hospitalized older adults. The outcomes which were examined included frailty; physical, psychological, and social domains; length of stay in hospital; re-hospitalization; mortality; patient satisfaction; and the need for post discharge placement.

RESULTS

After screening 7976 records and 243 full-text articles, seven studies (3 interventions) were included, involving 1009 hospitalized older patients. The quality of these studies was fair to poor and the risk of publication bias in the studies was low. Meta-analysis of the studies showed statistically significant differences between the intervention and control groups for the management of frailty in hospitalized older adults (ES = 0.35; 95% CI: 0. 067-0.632; z = 2.43; P < 0.015). However, none of the included studies evaluated social status, only a few of the studies evaluated other secondary outcomes. The analysis also showed that a Comprehensive Geriatric Assessment unit intervention was effective in addressing physical and psychological frailty, re-hospitalization, mortality, and patient satisfaction.

CONCLUSIONS

Interventions for hospitalized frail older adults are effective in management of frailty. Multidimensional interventions conducted by a multidisciplinary specialist team in geriatric settings are likely to be effective in the care of hospitalized frail elderly. Due to the low number of RCTs carried out in a hospital setting and the low quality of existing studies, there is a need for new RCTs to be carried out to generate a protocol appropriate for frail older people.

Aging in the USA: similarities and disparities across time and space

We study biological aging of elderly U.S. Americans born 1904-1966. We use thirteen waves of the Health and Retirement Study and construct a frailty index as the number of health deficits present in a person measured relative to the number of potential deficits. We find that, on average, Americans develop 5% more health deficits per year, that men age slightly faster than women, and that, at any age above 50, Caucasians display significantly fewer health deficits than African Americans. We also document a steady time trend of health improvements. For each year of later birth, health deficits decline on average by about 1%. This health trend is about the same across regions and for men and women, but significantly lower for African Americans compared to Caucasians. In non-linear regressions, we find that regional differences in aging follow a particular regularity, akin to the compensation effect of mortality. Health deficits converge for men and women and across American regions and suggest a life span of the American population of about 97 years.

Serum branched-chain amino acids are associated with leukocyte telomere length and frailty based on residents from Guangxi longevity county

Branched-chain amino acids (BCAAs) and telomere length are biologically associated with healthy aging. However, the association between them and their interaction on frailty remain unclear in humans. Here, a cross-sectional study based on residents from Guangxi longevity county was conducted to investigate the association of serum BCAAs, peripheral leukocyte telomere length (LTL) and frailty. A total of 1,034 subjects aged 20 to 110 years were recruited in the study. The real-time qPCR method and a targeted metabolomics approach based on isotope dilution liquid chromatography tandem mass spectrometry (LC/MS/MS) method were used for measurement of LTL and BCAAs, respectively. A frailty score defined as the proportion of accumulated deficits based on 24 aging-related items was used assess the health status of elderly subjects. First, we found that a higher concentration of BCAAs was significantly associated with longer LTL only in middle-aged subjects, independent of age and BMI (P < 0.05). In the oldest-old subjects, we identified a significantly inverse association between BCAAs and frailty score (P < 0.001), even after adjustment for age and BMI (P < 0.05). Additionally, we recognized a statistically significant synergetic interaction between BCAAs and LTL on frailty score in the oldest-old subjects by the general linear model (P = 0.042), although we did not find any significant association between LTL and frailty score. In summary, our findings suggest a potentially protective effect of circulating BCAAs on LTL and frailty based on the subjects from longevity county in East Asia and indicate a potential synergetic interaction between BCAAs and LTL in healthy aging.

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.