Fried frailty phenotype assessment components as applied to geriatric inpatients

Hypertension in frail older adults: current perspectives

Hypertension is one of the most common chronic diseases in older people, and the prevalence is on the rise as the global population ages. Hypertension is closely associated with many adverse health outcomes, including cardiovascular disease, chronic kidney disease and mortality, which poses a substantial threat to global public health. Reasonable blood pressure (BP) management is very important for reducing the occurrence of adverse events. Frailty is an age-related geriatric syndrome, characterized by decreased physiological reserves of multiple organs and systems and increased sensitivity to stressors, which increases the risk of falls, hospitalization, fractures, and mortality in older people. With the aging of the global population and the important impact of frailty on clinical practice, frailty has attracted increasing attention in recent years. In older people, frailty and hypertension often coexist. Frailty has a negative impact on BP management and the prognosis of older hypertensive patients, while hypertension may increase the risk of frailty in older people. However, the causal relationship between frailty and hypertension remains unclear, and there is a paucity of research regarding the efficacious management of hypertension in frail elderly patients. The management of hypertension in frail elderly patients still faces significant challenges. The benefits of treatment, the optimal BP target, and the choice of antihypertensive drugs for older hypertensive patients with frailty remain subjects of ongoing debate. This review provides a brief overview of hypertension in frail older adults, especially for the management of BP in this population, which may help in offering valuable ideas for future research in this field.

Dynamic associations between frailty and cognition over 4 years: A population-based study on adults aged ≥50 from 12 European countries

PURPOSE

This study aimed (1) to investigate autoregressive and cross-lagged associations between frailty and cognition over 4 years in a large sample of European citizens aged ≥50 years, (2) to examine the 4-year temporal associations' differences between sex and between active and inactive physical behaviour, and (3) to explore in the years 2011, 2013, and 2015 associations between cognitive performance and the pre-frailty and frailty conditions.

MATERIALS AND METHODS

This longitudinal analysis was conducted with 20,857 individuals (11,540 women) from 12 countries aged ≥50 years who responded to waves 4, 5, and 6 of the SHARE project. The variables analysed were frailty (SHARE-FI) and a general cognition index (Cogindex) calculated for each wave from verbal fluency, immediate recall, and delayed recall.

RESULTS

A greater propensity for cognitive impairment was found in women, as well as in pre-frail and frail individuals. There were no significant differences between the sexes for the autoregressive effect of frailty and Cogindex over 4 years. On the other hand, sedentary and active individuals differed in frailty between Time 1-2. Cross-lagged analyses indicated a significant difference for the sexes between frailty and Cogindex Time 1-3 and between Cogindex and frailty of Time 2-3. Sedentary and active differed significantly in the path of frailty on Cogindex between Time 2-3.

CONCLUSION

Health policies should increase surveillance of frailty, cognition, and level of physical activity in the older European population, with a special focus on women.

Pilot Testing of Useful Tools' Validity for Frailty Assessment in Greece: Translated PRISMA-7 Tool, Modified Fried Criteria and Clinical Frailty Scale

The importance of frailty in older people is getting constant recognition as an important aspect both in terms of public health, as well as at a personal level, for the appropriate management of an older person's health condition. This is reflected by the continuously increasing number of research studies carried out in several settings across different countries. Sometimes, this is very solid, but in other cases, there is a considerable gap in terms of accurate and well-grounded documentation of frailty status. This is the case in Greece, where we are missing clinically validated tools to approach frailty. We are missing frailty screening tools, such as, for instance, Program of Research on Integration of Services for the Maintenance of Autonomy 7 (PRISMA 7), the gold standard tool of Fried criteria, is somehow problematic since the question referring to physical activity originates from a questionnaire that has not been translated and validated, while Clinical Frailty Scale (CFS) has been validated for translation but not for the capacity to detect frailty. The aim of this study is to validate these tools for their accuracy to detect frailty by using a measurable index of frailty, previously proposed for use in clinical studies: the Short Physical Performance Battery (SPPB). Seventy-four male and female participants (mean age 80.47 years SD = ±7.45 years, minimum-maximum age = 65-95) have been evaluated for their frailty status using different tools. We observed that the PRISMA 7 translation detects frailty only when one question is removed at a cut-off of ≥2 and indicates a sensitivity of 88.1% and specificity of 99.9% with a good correlation with SPPB measurements (r = -0.858; p < 0.001). When CFS was validated using SPPB, it demonstrated a very good correlation (r = -0.838; p < 0.001 respectively) as was the case for the modified Fried Criteria (r = -0.725; p < 0.001). All items demonstrated a good correlation between them. We here propose that we can accurately assess frailty status in the community setting by using a modified version of Fried criteria, Clinical Frailty Scale translation in Greek, and we can screen for frailty by using the Greek translation of PRISMA 7 only after removing item 6 of the questionnaire.

Assessing frailty amongst older people admitted to hospital in a low-income setting: a multicentre study in northern Tanzania

BACKGROUND

Populations are ageing globally and Low- and Middle-Income Countries (LMICs) are experiencing the fastest rates of demographic change. Few studies have explored the burden of frailty amongst older people in hospital in LMICs, where healthcare services are having to rapidly adapt to align with the needs of older people. This study aimed to measure the prevalence of frailty amongst older people admitted to hospital in Tanzania and to explore their demographic and clinical characteristics.

METHODS

This study had a prospective observational design. Over a six-month period, all adults ≥ 60 years old admitted to medical wards in four hospitals in northern Tanzania were invited to participate. They were screened for frailty using the Clinical Frailty Scale (CFS) and the Frailty Phenotype (FP). Demographic and clinical characteristics of interest were recorded in a structured questionnaire. These included the Barthel Index, the Identification of Elderly Africans Instrumental Activities of Daily Living (IADEA-IADL) and Cognitive (IDEA-Cog) screens, the EURO-D depression scale and Confusion Assessment Method.

RESULTS

540 adults aged ≥ 60 were admitted, and 308 completed assessment. Frailty was present in 66.6% using the CFS and participants with frailty were significantly older, with lower levels of education and literacy, greater disability, greater comorbidity, poorer cognition and higher levels of delirium. Using the FP, 57.0% of participants were classed as frail though a majority of participants (n = 159, 51.6%) could not be classified due to a high proportion of missing data.

CONCLUSIONS

This study indicates that the prevalence of frailty on medical wards in northern Tanzania is high according to the CFS. However, the challenges in operationalising the FP in this setting highlight the need for future work to adapt frailty screening tools for an African context. Future investigations should also seek to correlate frailty status with long-term clinical outcomes after admission in this setting.

Using voice biomarkers for frailty classification

Clinicians use the patient's voice intuitively to evaluate general health and frailty. Voice is an emerging health indicator but has been scarcely studied in the context of frailty. This study explored voice parameters as possible predictors of frailty in older adults. Fifty-three participants over 70 years old were recruited from rehabilitation wards at a tertiary medical center. Participants' frailty was assessed using Rockwood frailty index and they were classified as most-frail (n = 33, 68%) or less-frail (n = 20, 32%). Participants were recorded counting from 1 to 10 and backwards using a smartphone recording application. The following voice biomarkers were derived: peak and average volume, peak/average volume ratio, pauses' total length, and pause length standard deviation. The most-frail group had a higher peak volume/average volume ratio (p = 0.03) and greater variance in lengths of pauses between speech segments (p = 0.002). These parameters indicate greater speech irregularity in the most-frail, compared to the less-frail. The most-frail group also had a longer total duration of pauses (p = 0.02). No statistically significant difference was found in peak and average volume (p = 0.75 and 0.39). Most-frail participants' speech had different characteristics, compared to participants in the less-frail group. This is a first step to developing an AI-based frailty assessment tool that can assist in identifying our most vulnerable patients.

The Prevalence of the Frailty Syndrome in a Hospital Setting-Is Its Diagnosis a Challenge? A Comparison of Four Frailty Scales in a Cross-Sectional Study

The study aimed to assess the prevalence of the frailty syndrome in older patients hospitalized in the geriatric ward depending on the diagnostic criteria used, the feasibility of particular diagnostic scales in hospitalized patients, and their compatibility; 416 patients (81.2 ± 6.91 years) admitted to the Department of Geriatrics of Hospital of the Ministry of the Interior and Administration in Bialystok within eight months were included in the study. Four diagnostic scales were used to identify the frailty syndrome: Fried criteria, 7-point Clinical Frailty Scale (CFS), 40-item Frailty Index (FI), and FRAIL Scale. Depending on the scale, the prevalence of frailty syndrome varied from 26.8% (FRAIL Scale), 52.3% (Clinical Frailty Scale), and 58.1% (Fried criteria) up to 62.9% (Frailty Index). We observed the highest feasibility for CFS (100%) and the lowest for the Fried scale (79.8%). The highest level of agreement was found between the CFS and Frailty Index, with 80.3% consistent ratings (Cohen Kappa 0.6). Patients in the geriatric ward are characterized by a high prevalence of frailty, although it differs depending on the criteria. The most difficult to use in daily practice was the Fried scale, while the Clinical Frailty Scale was determined feasible in all patients.

Functional outcomes of COVID-19 patients who underwent acute inpatient rehabilitation and the exploration of the benefits of adjunct robotic therapy and the effects of frailty

Objective

To describe the functional outcomes of post COVID-19 patients after inpatient rehabilitation and determine if patients who underwent adjunct daily robotic therapy with Andago had better functional outcomes than those who did not and if patients who were frail had worse functional outcomes than those who were pre-frail or not frail.

Design

Retrospective study of COVID-19 patients transferred for acute inpatient rehabilitation from 1 November 2021 to 31 December 2021.

Results

Post COVID-19 patients who underwent inpatient rehabilitation had an improvement in the Functional Independence Measure (FIM) (median 109 vs 82), Functional Ambulation Category(FAC) (median 3 vs 2), distance walked with physiotherapist (mean 143.5 vs 18.7 m), and the Hospital Anxiety and Depression Scale(HADS) (mean 4.5 vs 7.8) from baseline. Robotic therapy may be associated with a shorter rehabilitation medicine length of stay (median 13 vs 19.5 days) and a higher FIM efficiency (mean 2.3 vs 1.2). Patients with a higher frailty score may have a slower 10 Meter Walk Test (10MWT) speed at discharge (Spearman’s rho −0.542).

Conclusion

Post COVID-19 patients benefit from inpatient rehabilitation with a comprehensive rehabilitation program, and adjunct robotic therapy may be offered to further improve functional outcomes. Frailty may also be considered when establishing rehabilitation goals, as meaningful functional gains can still be achieved.

The effectiveness of nurse-led interventions to manage frailty in community-dwelling older people: a systematic review

BACKGROUND

The global increase in the number of frail older people and the accompanying increase in chronic conditions underline the need to develop effective health promotion and preventive interventions for these population groups. Wide ranging of physical, psychological, and social health factors influence frailty in older people and leads to increased vulnerability to many adverse outcomes. To reverse or reduce the progression of frailty, nurses play a pivotal role in delivering health promotion and preventive interventions. The purpose of the review is to determine the effectiveness of nurse-led interventions in reducing frailty in community-dwelling older people.

METHODS

The following electronic databases: PubMed, MEDLINE, Web of Science, SCOPUS, CINAHL, PsychInfo, and WHO Global Index Medicus were searched until June 2022. Nurse-led, "nurse led", education, training, intervention, program, teaching, frail*, fragile*, "frailty syndrome", debility, infirmity, elder*, aged*, old*, geriatric, "community based settings", "community-based", "community setting", community were the search terms. Before data extraction, eligible articles were assessed for their methodological quality. The JBI critical appraisal checklist for reporting experimental studies was utilised to appraise the methodological quality of the studies. Data were systematically examined using a narrative review to determine the effectiveness of the intervention.

RESULTS

Of the 156 studies identified, from the search, six studies with samples ranging from 40 to 1387 older people were eligible for inclusion in the review. Two quasi-experimental studies and one Randomised Controlled Trial (RCT) showed a moderate risk of bias. The Nurse-led frailty interventions used a multi-component intervention approach across the studies. The interventions reversed frailty progression, improve physical functioning, nutritional status, and quality of life, enhance perceptions of social support, improve mental health, and reduce depression.

CONCLUSIONS

Few studies have explored the effectiveness of a nurse-led intervention to decrease frailty in older people. Evaluating physical functioning, nutritional status, mental health, and quality of life in community-dwelling frail older people can contribute to developing appropriate interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID of CRD42022348064.

Comparison between FRAIL Scale and Clinical Frailty Scale in predicting hospitalization in hemodialysis patients

BACKGROUND

To assess the prevalence of frailty by the Clinical Frailty Scale (CFS) and the 5-item FRAIL scale and their association with hospitalization in hemodialysis (HD) patients.

METHODS

This was a prospective observational study. We included patients of both genders ≥ 18 years old in HD treatment for at least 3 months. Demographic, clinical, and routine laboratory data were retrieved from the medical charts. Two different frailty assessment tools were used, the CFS and the FRAIL scale. Participants were followed up for 9 months and hospitalizations for all causes were evaluated. A Venn diagram was constructed to show the overlap of possible frailty and pre-frailty. Cox regression was used to identify the association between frailty and hospitalization. The significance level was 5%.

RESULTS

A total of 137 subjects were included in the analysis. The median age was 61 (52-67) years and 60% were male. The hospitalization rate and mortality in 9 months were 22.6% and 7.29%, respectively. Regarding frailty, the overall prevalence was 13.8% assessed by CFS and 36.5% according to the FRAIL scale. In the Cox regression, frailty by FRAIL scale was associated with a 2.8-fold increase in the risk of hospitalization (OR = 2.880; 95% CI = 1.361-6.096; p = 0.006), but frailty assessed by the CFS was not associated with the need for hospitalization.

CONCLUSION

In HD patients, the FRAIL scale proved to be an easy-to-apply tool, identifying a high prevalence of frailty and being a predictor of hospital admission.

Mortality prediction of the frailty syndrome in patients with severe mitral regurgitation

In this prospective observational study, we investigated the impact of geriatric syndromes and frailty on mortality and evaluated the prognostic value of different frailty, nutritional, and geriatric assessment tools in high-risk patients with severe mitral valve regurgitation (MR) who were evaluated for mitral valve therapies including surgical, interventional, and conservative treatment options. We prospectively assessed multiple parameters including the CONUT Score, the Katz Index of independence in activities of daily living (ADL), the Fried Frailty Phenotype (FFP), and the Essential Frailty Toolset (EFT) Score in 127 patients with severe symptomatic MR requiring surgical/interventional treatment versus conservative monitoring. We compared their predictive value on mortality including multivariate regression analysis to identify the most suitable tool to predict outcomes in these patient groups. The frailty syndrome as assessed with the CONUT Score, Katz Index, EFT Score, and FFP was associated with higher rates of comorbidities, significantly higher risk scores such as logistic EuroSCORE, EuroSCORE II, and STS-PROM, and significantly higher mortality rates. The EFT Score and FFP were independent predictors of one-year all-cause mortality in our study cohort (EFT Score: HR 1.9, 95% CI 1.2 to 3.2; p = 0.01; FFP: HR 1.8, 95% CI 1.1 to 3.1; p = 0.015). Geriatric syndromes and frailty are associated with increased mortality in high-risk patients with symptomatic severe MR. The EFT Score and the FFP were independent predictors of one-year all-cause mortality.

Prediction of Nursing Home Admission Using the FRAIL-NH Scale Among Older Adults in Post-Acute Care Settings

OBJECTIVES

The FRAIL-NH scale was developed to identify frailty status in nursing home residents. The purpose of this study was to examine the utility of the FRAIL-NH scale for predicting nursing home admission among patients in post-acute care settings. Design/ Setting/ Participants: This single-center, prospective, observational cohort study included participants aged 65 years or older who were admitted to a community-based integrated care ward (CICW) between July 2015 and November 2020.

MEASUREMENTS

Using the CICW database, we retrospectively classified participants as robust, prefrail, or frail based on the FRAIL-NH scale the score by identifying variables from our database that were most representative of each component. The following data were collected: examination findings, CICW admission and discharge information, length of CICW stay, and nursing home admission. The participants were divided into two groups based on whether or not they were admitted to a nursing home after CICW discharge. The hazard ratios (HRs) and 95% confidence intervals (CIs) for nursing home admission were calculated according to the FRAIL-NH categories using the Cox proportional hazards models with reference to the robust group. In the multivariate adjusted model, we adjusted for age, sex, nutritional status, cognitive function, living status, and economic status.

RESULTS

Data of 550 older adults were analyzed, of which 118 were admitted and 432 were not admitted to a nursing home. The frail group had a higher risk of nursing home admission (HR, 2.22; 95% CI 1.32-3.76) than the robust group.

CONCLUSIONS

This study showed that the FRAIL-NH scale was beneficial for predicting nursing home admission among older adults in the post-acute care setting. Thus, assessment using the FRAIL-NH scale may help to consider preparation and support for life after discharge.

Relationship between preoperative malnutrition, frailty, sarcopenia, body composition, and anthropometry in elderly patients undergoing major pancreatic and biliary surgery

Objective

To analyze the correlation between preoperative nutritional status, frailty, sarcopenia, body composition, and anthropometry in geriatric inpatients undergoing major pancreatic and biliary surgery.

Methods

This is a cross-sectional study of the database from December 2020 to September 2022 in the department of hepatopancreatobiliary surgery, Beijing Hospital. Basal data, anthropometry, and body composition were recorded. NRS 2002, GLIM, FFP 2001, and AWGS 2019 criteria were performed. The incidence, overlap, and correlation of malnutrition, frailty, sarcopenia, and other nutrition-related variables were investigated. Group comparisons were implemented by stratification of age and malignancy. The present study adhered to the STROBE guidelines for cross-sectional study.

Results

A total of 140 consecutive cases were included. The prevalence of nutritional risk, malnutrition, frailty, and sarcopenia was 70.0, 67.1, 20.7, and 36.4%, respectively. The overlaps of malnutrition with sarcopenia, malnutrition with frailty, and sarcopenia with frailty were 36.4, 19.3, and 15.0%. There is a positive correlation between every two of the four diagnostic tools, and all six p-values were below 0.002. Albumin, prealbumin, CC, GS, 6MTW, ASMI, and FFMI showed a significantly negative correlation with the diagnoses of the four tools. Participants with frailty or sarcopenia were significantly more likely to suffer from malnutrition than their control groups with a 5.037 and 3.267 times higher risk, respectively (for frailty, 95% CI: 1.715-14.794, p = 0.003 and for sarcopenia, 95% CI: 2.151-4.963, p<0.001). Summarizing from stratification analysis, most body composition and function variables were worsen in the ≥70 years group than in the younger group, and malignant patients tended to experience more intake reduction and weight loss than the benign group, which affected the nutrition diagnosis.

Conclusion

Elderly inpatients undergoing major pancreatic and biliary surgery possessed high prevalence and overlap rates of malnutrition, frailty, and sarcopenia. Body composition and function deteriorated obviously with aging.

Application of a perioperative nursing strategy in the surgical treatment of elderly patients: a narrative review†

With the steady increase of older people in society, a progressively greater number of patients belonging to the geriatric group need surgical treatment. Since elderly patients with reduced physiological reserve and organ failure often have chronic diseases, geriatric syndrome, and other clinical problems, the perioperative nursing of elderly patients is more complicated. Therefore, we need to comprehensively consider clinical issues, such as patients’ preoperative status, surgical risks, and postoperative quality of life and life expectancy, and conduct comprehensive evaluations and holistic, individualized, and continuous nursing and therapy through the participation of interdisciplinary teams to achieve better curative effects. Here, the perioperative nursing of elderly patients is reviewed, including preoperative evaluation and nursing, intraoperative management, and postoperative nursing.

Frailty-aware care: giving value to frailty assessment across different healthcare settings

Healthcare systems need to adapt to better serve an aging population with complex presentations. Frailty assessments are a potential means to address this heterogeneity in aging to identify individuals at increased risk for adverse health outcomes. Furthermore, frailty assessments offer an opportunity to optimize patient care in various healthcare settings. While the vast number of frailty assessment tools available can be a source of confusion for clinicians, each tool has features adaptable to the constraints and goals of different healthcare settings. This review discusses and compares barriers, facilitators, and the application of frailty assessments in primary care, the emergency department/intensive care unit and surgical care to cover a breadth of settings with different frailty assessment considerations. The implementation of frailty-aware care across healthcare settings potentiates better healthcare outcomes for older adults.

Development of a standards-based phenotype model for gross motor function to support learning health systems in pediatric rehabilitation

INTRODUCTION

Research and continuous quality improvement in pediatric rehabilitation settings require standardized data and a systematic approach to use these data.

METHODS

We systematically examined pediatric data concepts from a pediatric learning network to determine capacity for capturing gross motor function (GMF) for children with Cerebral Palsy (CP) as a demonstration for enabling infrastructure for research and quality improvement activities of an LHS. We used an iterative approach to construct phenotype models of GMF from standardized data element concepts based on case definitions from the Gross Motor Function Classification System (GMFCS). Data concepts were selected using a theory and expert-informed process and resulted in the construction of four phenotype models of GMF: an overall model and three classes corresponding to deviations in GMF for CP populations.

RESULTS

Sixty five data element concepts were identified for the overall GMF phenotype model. The 65 data elements correspond to 20 variables and logic statements that instantiate membership into one of three clinically meaningful classes of GMF. Data element concepts and variables are organized into five domains relevant to modeling GMF: Neurologic Function, Mobility Performance, Activity Performance, Motor Performance, and Device Use.

CONCLUSION

Our experience provides an approach for organizations to leverage existing data for care improvement and research in other conditions. This is the first consensus-based and theory-driven specification of data elements and logic to support identification and labeling of GMF in patients for measuring improvements in care or the impact of new treatments. More research is needed to validate this phenotype model and the extent that these data differentiate between classes of GMF to support various LHS activities.

Frailty and Different Exercise Interventions to Improve Gait Speed in Older Adults after Acute Coronary Syndrome

Background and Objectives: The world’s population is rapidly aging, and it is estimated that, by 2050, every sixth person on earth will be older than 65 years. Around 30% of older adults entering cardiac rehabilitation (CR) meet the criteria of frailty. Frailty identification has not been included in the routine evaluation of CR patients yet, and there is a lack of evidence on what training regimen for improving physical performance in frail people is optimal. Therefore, the aim of our study was to determine the prevalence of frailty and to evaluate the effect of two different complementary training programs on the gait speed of older vulnerable and frail patients with acute coronary syndrome and mid-range-to-preserved left ventricular ejection fraction (≥40%) during short-term CR. Materials and Methods: This randomized controlled trial was conducted from January 2020 to September 2021. CR participants (n = 97) with a mean age of 73.1 ± 5.3 years were randomly allocated into three groups: control (CG, n = 32), intervention-1 (IG-1, n = 32) and intervention-2 (IG-2, n = 33). The patients of all three groups attended a usual inpatient CR program, and two intervention groups additionally received different resistance and balance training programs 3 days a week: the IG-1 underwent complementary training with traditional means of physical therapy, while the IG-2 underwent complementary training with mechanical devices. The mean CR duration was 18.9 ± 1.7 days. Frailty was assessed with the Edmonton Frail Scale, and the 5 m walk test was used to evaluate gait speed. Results: Frailty was determined in 37.1% of participants, and 42.3% met the criteria of being vulnerable. After CR, the gait speed of frail and vulnerable patients significantly improved in all three groups (p < 0.05). In the IG-2, slow gait speed was reversed to normal in the overwhelming majority of patients (p < 0.05), while the CG had the greatest proportion of patients who remained to be slow after CR (p < 0.05). Conclusions: A considerable part of patients entering CR are frail or vulnerable; therefore, it is of crucial importance to assess frailty status in all older people. All three CR programs improved gait speed in frail and vulnerable older patients with ischemic heart disease. Complementary resistance and balance training with mechanical devices more effectively reversed slow gait speed to normal during short-term CR.

Impact of frailty on short term outcomes, resource use, and readmissions after transcatheter mitral valve repair: A national analysis

Background

Treatment options for mitral regurgitation range from diuretic therapy, to surgical and interventional strategies including TMVR in high-risk surgical candidates. Frailty has been associated with inferior outcomes following hospitalizations for heart failure and in open cardiac surgery.

Objective

The purpose of the present study was to evaluate the impact of frailty on clinical outcomes and resource use following transcatheter mitral valve repair (TMVR).

Methods

Adults undergoing TMVR were identified using the 2016–2018 Nationwide Readmissions Database, and divided into Frail and Non-Frail groups. Frailty was defined using a derivative of the Johns Hopkins Adjusted Clinical Groups frailty indicator. Generalized linear models were used to assess the association of frailty with in-hospital mortality, complications, nonhome discharge, hospitalization costs, length of stay, and non-elective readmission at 90 days. Average marginal effects were used to quantify the impact of frailty on predicted mortality.

Results

Of 18,791 patients undergoing TMVR, 11.6% were considered frail. The observed mortality rate for the overall cohort was 2.2%. After adjustment, frailty was associated with increased odds of in-hospital mortality (AOR 1.8, 95% CI 1.2–2.6), corresponding to an absolute increase in risk of mortality of 1.1%. Frailty was associated with a 2.7-day (95% CI 2.1–3.2) increase in postoperative LOS, and $18,300 (95% CI 14,400–22,200) increment in hospitalization costs. Frail patients had greater odds (4.4, 95% CI 3.6–5.4) of nonhome discharge but similar odds of non-elective 90-day readmission.

Conclusions

Frailty is independently associated with inferior short-term clinical outcomes and greater resource use following TMVR. Inclusion of frailty into existing risk models may better inform choice of therapy and shared decision-making.

Effects of lower limb resistance exercise on muscle strength, physical fitness, and metabolism in pre-frail elderly patients: a randomized controlled trial

Background

Few studies examined interventions in frail elderly in China, while the awareness of applying interventions to prevent frailty in pre-frail elderly is still lacking. This study aimed to explore the effects of lower limb resistance exercise in pre-frail elderly in China.

Methods

This was a randomized controlled trial of patients with pre-frailty. The control group received routine care, while the exercise group received a 12-week lower limb resistance exercise based on routine care. The muscle strength in the lower limbs, physical fitness, and energy metabolism of the patients was evaluated at admission and after 12 weeks of intervention.

Results

A total of 60 pre-frail elderly were included in this study. The patients were divided into the exercise group (n = 30) and control group (n = 30) by random grouping. There were 17 men and 13 women aged 65.3 ± 13.4 in the exercise group, and 15 men and 15 women aged 67.6 ± 11.9 years in the control groups. The Barthel index was 80.3 ± 10.6 and 85.1 ± 11.6, respectively. The characteristics of the two groups were not significantly different before intervention (all p > 0.05). The results of repeated measurement ANOVA showed that there was statistically significant in crossover effect of group * time (all p < 0.05), that is, the differences of quadriceps femoris muscle strength, 6-min walking test, 30-s sit-to-stand test, 8-ft “up & go” test, daily activity energy expenditure and metabolic equivalent between the intervention group and the control group changed with time, and the variation ranges were different. The main effects of time were statistically significant (all p < 0.05), namely, femoris muscle strength, 6-min walking test, 30-s sit-to-stand test, 8-ft “up & go” test, daily activity energy expenditure and metabolic equivalent of the intervention group and the control group were significantly different before and after intervention. The main effects of groups were statistically significant (p < 0.05), namely, femoris muscle strength, 6-min walking test, 30-s sit-to-stand test, daily activity energy expenditure and metabolic equivalent before and after intervention were significantly different between the intervention group and the control group, while there was no significant differences in 8-ft “up & go” test between groups.

Conclusion

Lower limb resistance exercise used for the frailty intervention could improve muscle strength, physical fitness, and metabolism in pre-frail elderly.

Trial registration

ChiCTR, ChiCTR2000031099. Registered 22 March 2020, http://www.chictr.org.cn/edit.aspx?pid=51221&htm=4

Cognitive Frailty and 30-Day Mortality in a National Cohort of Older Chinese Inpatients

Purpose

Studies exploring the association of cognitive frailty and mortality have been mainly based on community settings or nursing home settings. The aim of our study was to explore the association between cognitive frailty and 30-day mortality among older Chinese inpatients.

Patients and Methods

A national cohort study was performed in different hospitals in China. A baseline survey was conducted from October 2018 and February 2019. Trained investigators collected the 30-day mortality. Cognitive impairment and frailty were defined by the Mini-Cog and FRAIL scale, respectively. Multivariate regression was used to explore the association between cognitive impairment and frailty status with 30-day mortality.

Results

Of these participants, there were 3891 (41.91%) women and 5392 (58.09%) men, with an average age of 72.41 (SD=5.72). The prevalence of cognitive frailty was 5.44%. After adjusting for age, gender, education, depression and activities of daily living (ADL), the odds ratios (ORs) for 30-day mortality among inpatients were 3.43 (95% CI: 1.80-6.55) for cognitive frailty, 1.85 (95% CI: 1.01-3.41) for frailty only, and 1.43 (95% CI: 0.77-2.65) for cognitive impairment only compared to the reference group (neither frailty nor cognitive impairment). In addition, the discrimination of 30-day mortality was higher among patients with cognitive frailty (area under the curve =0.676 [95% CI: 0.621-0.731]) than either frailty (area under the curve =0.644 [95% CI: 0.594-0.694]) or cognitive impairment (area under the curve = 0.606 [95% CI: 0.556-0.655]) separately. Stratified analysis showed that these associations still existed when grouped by gender.

Conclusion

Our study found that Chinese inpatients with cognitive frailty had a higher risk of 30-day mortality than those without frailty and cognitive impairment, suggesting that clinicians should be encouraged to perform early screening of patients with frailty and cognitive impairment and carry out effective interventions to reverse cognitive frailty syndrome.

Carnitine Serum Levels in Frail Older Subjects

Frailty is an expression that reconciles and condenses loss of autonomy, both physical and cognitive decline and a wide spectrum of adverse outcomes due to aging. The decrease in physical and cognitive activity is associated with altered mitochondrial function, and energy loss and consequently morbidity and mortality. In this cross-sectional study, we evaluated the carnitine levels in frailty status. The mean serum concentrations of total carnitine (TC) were lower in frail elderly subjects than in prefrail ones (p = 0.0006), higher in frail vs. robust subjects (p < 0.0001), and higher in prefrail vs. robust subjects (p < 0.0001). The mean serum concentrations of free carnitine (FC) were lower in frail elderly subjects than in prefrail ones (p < 0.0001), lower in frail vs. robust subjects (p < 0.0001) and lower in prefrail vs. robust subjects (p = 0.0009). The mean serum concentrations of acylcarnitine (AC) were higher in frail elderly subjects than in prefrail ones (p = 0.054) and were higher in pre-frail vs. robust subjects (p = 0.0022). The mean urine concentrations of TC were lower in frail elderly subjects than in prefrail ones (p < 0.05) and lower in frail vs. robust subjects (p < 0.0001). The mean urine concentrations of free carnitine were lower in frail elderly vs. robust subjects (p < 0.05). The mean urine concentrations of acyl carnitines were lower in frail elderly subjects than those in both prefrail (p < 0.0001) and robust subjects (p < 0.0001). Conclusion: high levels of carnitine may have a favorable effect on the functional status and may treat the frailty status in older subjects.

Frailty Tools for Assessment of Long-term Prognosis After Acute Coronary Syndrome

Objective

To evaluate the 5 components of the Fried frailty phenotype (self-reported unintentional weight loss, physical activity questionnaire, gait speed, grip strength, and self-reported exhaustion) for long-term outcomes in elderly survivors of acute coronary syndrome.

Methods

A total of 342 consecutive patients (from October 1, 2010, to February 1, 2012) were included. The 5 components of the Fried score and albumin concentration, as malnutrition index, were assessed before hospital discharge. Patients were followed up until April 2020 (median follow-up, 8.7 years). The end point was postdischarge all-cause mortality.

Results

Mean ± SD age was 77±7 years and mean ± SD Fried score was 2.0±1.1 points. A total of 216 (63%) patients died. After adjusting for clinical covariates, the Fried phenotype was associated with mortality (per points, hazard ratio [HR], 1.35; 95% CI, 1.17 to 1.57; P<.001). Among Fried components, physical activity (HR, 2.21; 95% CI, 1.34 to 3.65; P=.002) and gait speed (HR, 1.77; 95% CI, 1.29 to 2.43; P<.001) were the deficits independendtly associated with mortality. Albumin level provided further prognostic information (per increase in g/dL; HR, 0.63, 95% CI, 0.45 to 0.88; P=.007). The model adding the components of the Fried score and albumin level to the clinical model showed the highest risk reclassification (integrated discrimination improvement, 0.040; 95% CI, 0.018 to 0.075; P=.001; continuous net reclassification improvement, 0.291; 95% CI, 0.132 to 0.397; P=.001) in comparison with the model using clinical covariates alone.

Conclusion

Frailty assessment using the Fried phenotype has prognostic value for long-term mortality in elderly survivors of acute coronary syndrome. Physical activity and gait speed are the predictive components of the Fried score. Albumin level provides incremental prognostic information.

Association of Diagnostic Coding-Based Frailty and Outcomes in Patients With Heart Failure: A Report From the Veterans Affairs Health System

Background

The aim of this study was to determine whether frailty is associated with increased admission and mortality risk in the setting of heart failure.

Methods and Results

This retrospective cohort analysis included patients treated within the Veterans Affairs Health System who had International Classification of Diseases, Ninth Revision (ICD‐9) codes for heart failure on 2 or more dates over a 2‐year period. The clinical variables identifiable in claims data, such as demographic variables and markers of physical and cognitive dysfunction, were used to identify patients meeting the frailty phenotype. Of 388 785 extracted patients with coding of heart failure between 2015 and 2018, 163 085 patients (41.9%) with ejection fraction (EF) measurement were included in the present analysis (38.3% with reduced EF and 61.7% with preserved EF). There were 16 660 patients (10.2%) who were identified as frail (9.1% in heart failure with reduced EF and 10.9% in heart failure with preserved EF). Frail patients were older, more often depressed, and were likely to have been admitted in the previous year. One‐year all‐cause mortality rate was 9.7% and 28.1%, and admission rate was 58.1% and 79.5% for nonfrail and frail patients, respectively. Frailty was associated with mortality and admission risk compared with the nonfrail group (adjusted odds ratio [OR], 1.71; 95% CI, 1.65–1.77 for mortality; adjusted OR, 1.29; 95% CI, 1.24–1.34 for admission) independent of EF.

Conclusions

Frailty based on diagnostic coding was associated with particularly higher risk of mortality despite adjustment for known clinical variables. Our findings underscore the importance of nontraditional parameters in the prognostic assessment.

Examining Frailty Phenotype Dimensions in the Oldest Old

INTRODUCTION

Frailty has been studied among the old population due to its association with negative outcomes. Presently there is no gold standard for measuring frailty, but several studies have used the frailty phenotype of Fried consisting of five components (weakness, slowness, unintentional weight loss, exhaustion, and low physical activity) that classify individuals as robust, pre-frail, or frail, depending on the number of components affected, respectively, zero, one or two, and three or more. This study aims to explore the specific contribution of each of these components to the frailty phenotype in a sample of oldest old community-dwelling individuals.

MATERIALS AND METHODS

Individuals aged 80+ years old living in the community (N = 142) participated in this study. Sociodemographic data (age, sex, educational level, and marital status) and Fried's frailty phenotype were collected. Descriptive analysis summarized sociodemographic information and the frailty components. Multiple correspondence analysis (MCA) was performed to detect and explore relationships between frailty's five components.

RESULTS

Participants had a mean age of 88.07 years (SD = 5.30 years) and were mainly women (73.9%). The majority of the sample were considered frail (71.8%) and pre-frail (24.7%), and the most recurrent component for both groups was slowness. From the MCA analysis, a two-dimension solution was considered the most adequate, with 53.47% of variance explained. Dimension 1 (32.21% of variance explained) showed weakness as the most discriminant component; dimension 2 (21.26% of variance explained) showed unintentional weight loss as the most discriminant component.

DISCUSSION

Results revealed a high number of pre-frail and frail participants. MCA proved to add an important understanding in examining the frailty phenotype; it revealed weakness as the most discriminant component for dimension 1, suggesting a high association with the frailty phenotype. MCA also identified two main features of frailty: one related with physical features (motor behavioral and grip strength) including weakness, low physical activity, and slowness; and the second related with intrinsic conditions (unintentional weight loss and exhaustion).

CONCLUSION

This study corroborates the need of a differentiated approach to the frailty phenotype among very old individuals, bringing for consideration the specific influence of its components.

Associations of Frailty Status with Low-Mileage Driving and Driving Cessation in a Cohort of Older Drivers

The US older adult population is projected to considerably increase in the future, and continued driving mobility is important for health aspects in populations with fewer transportation alternatives. This study evaluated whether frailty is associated with low-mileage driving (<1865 miles per year) and driving cessation among older adults. Baseline demographics and health data were collected for 2990 older drivers via in-person assessments and questionnaires, with 2964 reporting baseline frailty data. Multivariable log-binomial regression models were used to evaluate the association between baseline frailty status and low-mileage driving. Multivariable Cox proportional hazards regression were used to evaluate the association between baseline frailty status and driving cessation. For every unit increase in frailty, the estimated adjusted risk of driving fewer than 1865 miles/year increased by 138% (adjusted risk ratio: 2.38, 95% CI: 1.63-3.46). Relative to older drivers who were not frail, the adjusted hazard ratios of driving cessation were 4.15 (95% CI: 1.89-9.10) for those classified as prefrail and 6.08 (95% CI: 1.36-27.26) for those classified as frail. Frailty is positively associated with low-mileage driving status and driving cessation in a dose-response fashion. Public health interventions that reduce frailty, such as physical activity, may help older drivers maintain safe and independent mobility.

Medication exposure and frailty in older community-dwelling patients: a cross-sectional study

Objective To investigate the association between the medication exposure, measured by the polypharmacy/excessive polypharmacy and the anticholinergic and/or sedative drug exposure, on frailty status among French older community-dwelling patients. Setting day-care unit in France (Lyon), with retrospective data from July, 2017 to March, 2018. Method This monocentric cross-sectional study included community-dwelling patients aged 65 years and over and admitted at the day-care unit for a geriatric evaluation. Frailty was assessed according to the frailty phenotype, described by Fried et al. Polypharmacy and excessive polypharmacy were defined as the concomitant use of 5-9 and 10 or more drugs, respectively. The cumulative anticholinergic and sedative exposure was measured using the drug burden index (DBI). The DBI score was presented in 4 differentiated scores: a null score (DBI = 0), a combined score (anticholinergic and sedative score), an anticholinergic score, and a sedative score. The association between medication and frailty was assessed by logistic regression models controlled for multiple potential confounders. Main outcome measure Association between medication exposure (polypharmacy, anticholinergic and sedative exposure) and frailty. Results In this study, 403 patients were included: 44.7% were frail and 40.7% were pre-frail. Polypharmacy and excessive polypharmacy affected 44.7% and 17.1% of the population respectively. The mean DBI was 0.33 ± 0.43, with 16.4% of patients with only sedative exposure, 9.7% with only anticholinergic exposure and 33.0% with both exposures. After adjustment, polypharmacy and excessive polypharmacy were associated with frailty with adjusted odds ratios (95% confidence interval) of 2.18 (1.03-4.22) and 2.72 (1.01-7.37) respectively. The cumulative exposure to anticholinergic and sedative drugs (combined score) was significantly associated to an increased risk for frailty with adjusted odds ratios (95% confidence interval) of 3.54 (1.47-8.57). Conclusion The study showed that polypharmacy and cumulative anticholinergic and sedative exposure are associated with frailty. Further research should address the potential benefit of collaborative medication review for preventing medication-associated frailty.

Reported Weight Change in Older Adults and Presence of Frailty

OBJECTIVE

A 5% change in weight is a significant predictor for frailty and obesity. We ascertained how self-reported weight change over the lifespan impacts rates of frailty in older adults.

METHODS

We identified 4,984 subjects ≥60 years with body composition measures from the National Health and Nutrition Examination Survey. An adapted version of Fried's frailty criteria was used as the primary outcome. Self-reported weight was assessed at time current,1 and 10 years earlier and at age 25. Weight changes between each time point were categorized as ≥ 5%, ≤5% or neutral. Logistic regression assessed the impact of weight change on the outcome of frailty.

RESULTS

Among 4,984 participants, 56.5% were female, mean age was 71.1 years, and mean BMI was 28.2kg/m2. A weight loss of ≥ 5% had a higher association with frailty compared to current weight, age 25 (OR 2.94 [1.72,5.02]), 10 years ago (OR 1.68 [1.05,2.69]), and 1 year ago (OR 1.55 [1.02,2.36]). Weight gain in the last year was associated with increased rate of frailty (1.59 [1.09,2.32]).

CONCLUSION

There is an association between frailty and reported weight loss over time while only weight gain in the last year has an association with frailty.

Exploring the association between subjective cognitive decline and frailty: the Hellenic Longitudinal Investigation of Aging and Diet Study (HELIAD)

Background: Subjective cognitive decline (SCD) refers to self-evaluations of impairment in cognitive functions in the absence of objective deficits. Frailty is a multidimensional syndrome that results in increased vulnerability. Both terms are associated with cognitive decline and increased incidence of dementia. The aim of this study was to explore potential associations between SCD and frailty in elderly individuals.Methods: In this cross-sectional study, we included 1454 participants aged 65 and older from the Hellenic Longitudinal Investigation of Aging and Diet (HELIAD) study. Individuals with a diagnosis of dementia, mild cognitive impairment, severe anxiety or depression were excluded. SCD were assessed with eighteen questions categorized into cognitive domains. Frailty was assessed according to the Fried definition, the Frailty Index (FI) and the Tilburg Frailty Indicator (TFI). Logistic regression analysis was used to investigate the association.Results: Lower educational level, female sex and low socioeconomic status were found to be associated with frailty and more SCD complaints. Having two or more types of SCD complaints was significantly associated with frailty according to all frailty definitions. All types of SCD complaints were significantly associated with the FI and the TFI. In addition, SCD complaints concerning problems requiring mathematical reasoning had the strongest association with frailty.Conclusion: We found that SCD complaints may be a valid indicator of frailty in cognitively unimpaired older people. We believe that SCD may provide a crucial proactive assessment to detect frailty and to implement programs that will help maintain good health and quality of life during aging.

Frailty Prevalence in the COMPASS-ND Study of Neurodegenerative Disorders

Background

Frailty is characterized by increased vulnerability to adverse health outcomes. The prevalence of frailty across neurodegenerative disorders (NDD) is largely unknown. Symptoms of frailty and NDD overlap, calling into question a tautology in some frailty instruments. Our objectives were 1) to construct a Frailty Index (FI) independent of NDD symptoms, and 2) to estimate frailty prevalence in a broad NDD cohort using both the Frailty Phenotype (FP) and the constructed FI as measures.

Methods

Data from the Canadian COMPASS-ND cohort study were assessed for applicability to FI construction. Frailty status according to FI and FP criteria were ascertained for each participant.

Results

81 items were selected for the FI. In the cohort (150 participants; 46% women; mean age 73.6±7.0; 10 NDD subgroups), frailty was identified in 11% and 14% of participants according to the FI and FP, respectively. The difference between estimates was not significant. The FP classified most participants (84%) as pre-frail.

Conclusion

The presence of frailty elements, regardless of whether they are part of NDD, is likely to influence health status. Given the FP identified a large proportion of the cohort as pre-frail or frail, it is likely worthwhile to identify frailty in the context of NDD.

Gait Speed and Mood, Cognition, and Quality of Life in Older Adults With Atrial Fibrillation

Background

Low gait speed has been linked with impaired mood, cognition, and quality of life (QOL) in older adults. We examined whether low gait speed was associated with impaired mood, cognition, and QOL among older adults with atrial fibrillation (AF).

Methods and Results

Participants (n=1185) had a diagnosis of AF, aged ≥65 years, CHA₂DS₂VASc ≥2 and had no contraindications to anticoagulation. Participants completed a 15‐foot walk test, and low gait speed was categorized using cutoffs from the Fried Frailty Index. Participants self‐reported measures of depressive symptoms (Patient Health Questionnaire 9 ≥10), anxiety symptoms (Generalized Anxiety Disorder 7 ≥10), cognitive impairment (Montreal Cognitive Assessment ≤23), and potentially impaired Atrial Fibrillation Effect Quality‐of‐Life Questionnaire <80. Participants were on average aged 75.3 (SD: 7.0) years, 48.0% were women, and 85.5% were non‐Hispanic white; 85.6% were taking an oral anticoagulant, 26.1% had low gait speed, 8.4% had elevated depressive symptoms, 5.7% had elevated anxiety symptoms, 41.1% were cognitively impaired, and 41.6% had potentially impaired AF‐related QOL. Participants with low gait speed were significantly more likely to have elevated depressive symptoms (adjusted odds ratio: 2.1, 95% CI: 1.3–3.4), elevated anxiety symptoms (adjusted odds ratio: 2.2, 95% CI: 1.2–3.9), and cognitive impairment (adjusted odds ratio: 1.5, 95% CI: 1.1–2.1). Impaired AF‐related QOL did not differ by gait speed after adjustment for clinical characteristics (adjusted odds ratio: 1.1, 95% CI: 0.8–1.5).

Conclusions

Twenty‐six percent of older adults with AF had low gait speed, and low gait speed was associated with impaired mood and cognition. Further research is needed to determine whether declines in gait speed lead to impaired mood and cognition or whether these conditions develop concurrently.

Associations Between Cognitive Functions and Physical Frailty in Patients With Parkinson's Disease

Background: Parkinson’s disease (PD) is a neurodegenerative disease manifested by both motor and non-motor dysfunctions and co-existence of cognitive impairment and physical frailty is common. Given that research in this area is limited, a better understanding of associated factors with physical frailty could provide a focused screening method and facilitate early intervention in PD.

Methods: Seventy-six patients with idiopathic PD were recruited and Fried’s criteria of physical frailty were used to group all participants. Comprehensive cognitive tests and clinical characteristics were measured, and univariate and multivariate analysis was performed to explore the relationship between clinical factors or neuropsychological functions.

Results: Twenty-nine patients with PD (38%) exhibited physical frailty. Compared to PD patients without frailty, PD patients with frailty were older in age and demonstrated worse disease severity and poorer cognitive functions, including attention, executive function, memory, speech and language, and visuospatial function (p < 0.05). Further, stepwise logistic regression analysis revealed that disease severity by the Unified Parkinson’s Disease Rating Scale (UPDRS) total score (OR: 1.065; 95% CI: 1.033–1.099) and executive function (OR: 0.724; 95% CI: 0.581–0.877) were independent risk factors for predicting physical frailty (p = 0.003 and 0.002). The best cut-off points are 46 in UPDRS (sensitivity: 62.1%; specificity: 91.5%).

Conclusions: Executive function impairment is an independent risk factor for the development of physical frailty with disease progression. Awareness of such comorbidity might provide a screening tool to facilitate investigation in their underlying etiology and early intervention for frailty prevention.

The Heart Failure "Pandemic" in Japan: Reconstruction of Health Care System in the Highly Aged Society

An increase in the number of patients with heart failure is an international health-related problem. In advanced countries, the number of such patients has rapidly increased since the beginning of the 21^st century, raising an important issue regarding medical practice and public health. In 2010, the concept of “heart failure pandemic” was proposed, and it has been recognized as a global social/economic issue. In particular, the number of elderly patients with heart failure has increased with the rapid aging of society and a decrease in the number of children in Japan. A rapid increase in the number of heart failure patients increases stress and social disease-related/medical economic burdens on individuals and their families. The prognosis of patients with chronic heart failure is unfavorable, and the quality of life markedly reduces. To improve the prognosis of elderly patients with heart failure and reduce the readmission rate, the innovation of a medical-care-providing system for heart failure is required. In addition to the provision of medical practice based on a potent heart failure disease control program, manifold strategies, such as lifestyle improvements, self-care practice, cardiac rehabilitation, and environmental intervention, are essential. It is necessary to innovate hospital-based medical practice to a regional-care-system-based medical care system. In addition, to efficiently promote future heart failure strategies, an investigational study with disease registration must be conducted. Recently a new basic act on countermeasures to cardiovascular diseases has been established which may help the reform for this purpose.

Osteoporosis therapy in patients with inflammatory rheumatic diseases and osteonecrosis of the jaw

BACKGROUND AND OBJECTIVES

The aim of the present study was to assess the prevalence of medication-related osteonecrosis of the jaw (MRONJ) in osteoporosis patients suffering from inflammatory rheumatic diseases, as well as to assess the prevalence of relevant dental, behavioral, and medical risk factors for MRONJ.

MATERIALS AND METHODS

A total of 198 patients with inflammatory rheumatic diseases and osteoporosis therapy were recruited from a tertiary rheumatological/immunological referral center between June 2015 and September 2016. They were assessed using a structured interview. A maxillofacial surgeon later examined patients complaining of possible symptoms of osteonecrosis. In cases of osteonecrosis, dental records were obtained and evaluated. Preventive measures taken and dental as well as other clinical risk factors were evaluated.

RESULTS

Of the 198 patients, three suffered from osteonecrosis of the jaw, none of whom had any history of malignant disease or radiation therapy, resulting in a prevalence of 1.5%. Of these three patients, only one was given bisphosphonates intravenously (i.v.), whereas all three had been treated orally. All three diagnoses of MRONJ had been previously known to the patients and their maxillofacial surgeons. Two of the patients had rheumatoid arthritis, and one patient suffered from large vessel vasculitis. Long anti-osteoporotic treatment duration, low functional status, and low bone density of the femur were significantly associated with MRONJ development.

CONCLUSION

Inflammatory rheumatic diseases constitute a risk factor for MRONJ in patients treated with bisphosphonates for osteoporosis. Patients should be counseled accordingly and should be offered dental screening and regular dental check-ups.

Current situation of frailty screening tools for older adults

Frailty is a geriatric syndrome associated with adverse outcomes such as falls, disability, and mortality. Frailty is common and contributes to rising health care costs. Early screening and timely tailored intervention may effectively prevent or delay the adverse outcomes in older adults. Studies on frailty and its specific measurement tools are increasing in number, but the debate on the screening instruments remains. Currently, self-reported screening tools can identify frailty and predict the risk of adverse outcomes in older adults. Because they are easy to use and quickly provide information, self-reported frailty screening tools have significant implication in primary care settings and clinics. We reviewed the frailty screening instruments in older adults and proposed a two-step pathway for frailty identification, and to manage declines in intrinsic capacity as well as boost resilience.

Urologic symptoms and burden of frailty and geriatric conditions in older men: the Aging Study of PyeongChang Rural Area

Purpose

Frailty is an important consideration in the management of lower urinary tract symptoms and erectile dysfunction in older men; frailty increases vulnerability to treatment-related adverse outcomes, but its burden is not known. The authors aimed to examine the burden of frailty and associated geriatric conditions in community-dwelling older men.

Patients and methods

A cross-sectional study was conducted with 492 community-dwelling older men (mean age, 74.2 years; standard deviation, 5.6 years). All the participants were administered the International Prostate Symptom Score (IPSS) (range: 0-35) and a five-item version of the International Index of Erectile Function (IIEF-5) (range: 5-25). Frailty phenotype was assessed based on exhaustion, inactivity, slowness, weakness, and weight loss. Prevalence of frailty phenotype and geriatric conditions were assessed by the IPSS severity category (mild, 0-7; moderate, 8-19; severe, 20-35 points) and the first IIEF-5 question, which assesses the confidence in erectile function (low, 1-2; moderate, 3; high, 4-5 points).

Results

Older men with severe urologic symptoms had a high prevalence of frailty. According to the IPSS questionnaire, the prevalence of frailty was 7.3% (21/288) in the mild category, 16.3% (26/160) in the moderate category, and 43.2% (19/44) in the severe category. Participants in the severe IPSS category showed high prevalence of dismobility (45.5%), multimorbidity (43.2%), malnutrition risk (40.9%), sarcopenia (40.9%), and polypharmacy (31.8%). According to erectile confidence based on the first IIEF-5 question, the prevalence of frailty was 18.7% (56/300) for low confidence, 5.3% (6/114) for moderate confidence, and 5.1% (4/78) for high confidence. Participants with low confidence in erectile function showed high prevalence of sarcopenia (39.0%), multimorbidity (37.7%), dismobility (35.7%), malnutrition risk (33.3%), and polypharmacy (23.0%).

Conclusion

The prevalence of frailty and geriatric conditions was higher in older men with severe urologic symptoms. A frailty screening should be routinely administered in urology practices to identify older men who are vulnerable to treatment-related adverse events.

Grip strength as a frailty diagnostic component in geriatric inpatients

BACKGROUND

Frailty has emerged as a key medical syndrome predictive of comorbidity, disability, institutionalization and death. As a component of the five frailty phenotype diagnostic criteria, patient grip strength deserves attention as a simple and objective measure of the frailty syndrome. The aim of this study was to assess conditions that influence grip strength in geriatric inpatients.

PATIENTS AND METHODS

The study group consisted of 80 patients aged 78.6±7.0 years [Formula: see text], with 68.8% women, admitted to the Department of Geriatrics. A comprehensive geriatric assessment was complemented with assessment for the frailty phenotype as described by Fried et al for all patients in the study group. Functional assessment included Barthel Index of Activities of Daily Living (Barthel Index), Instrumental Activities of Daily Living Scale and Mini-Mental State Examination.

RESULTS

Three or more frailty criteria were positive in 32 patients (40%), while 56 subjects (70%) fulfilled the frailty criterion of weakness (grip strength test). Multivariate linear regression analysis revealed that two independent measures showed positive association with grip strength - Mini-Mental State Examination score (β=0.239; P=0.001) and statin use (β=0.213; P=0.002) - and four independent measures were negatively associated with grip strength - female sex (β=-0.671; P<0.001), C-reactive protein (β=-0.253; P<0.001), prior myocardial infarction (β=-0.190; P=0.006) and use of an antidepressant (β=-0.163; P=0.018). Low physical activity was identified as the only independent qualitative frailty component associated with 2-year mortality in multivariate logistic regression analysis after adjustment for age and sex (odds ratio =6.000; 95% CI =1.357-26.536; P=0.018).

CONCLUSION

Cognitive function, somatic comorbidity and medical treatment affect grip strength as a measure of physical frailty in geriatric inpatients. Grip strength was not predictive of 2-year mortality in this group.

Operationalizing a frailty index using routine blood and urine tests

Background

Uncomplicated frailty instruments are desirable for use in a busy clinical setting. The aim of this study was to operationalize a frailty index (FI) from routine blood and urine tests, and to evaluate the properties of this FI compared to other frailty instruments.

Materials and methods

We conducted a secondary analysis of a prospective cohort study on 306 patients aged ≥65 years hospitalized on geriatric wards. An FI comprising 22 routine blood parameters and one standard urine parameter (FI-Lab), a 50-item FI based on a comprehensive geriatric assessment (FI-CGA), a combined FI (FI-combined [items from the FI-Lab + others from the FI-CGA]), the Clinical Frailty Scale, rule-based frailty definition, and frailty phenotype were operationalized from data obtained during patients’ hospital stays (ie, before discharge [baseline examination]). Follow-up data were obtained up to 1 year after the baseline examination.

Results

The mean FI-Lab score was 0.34±15, with an upper limit of 0.74. The FI-Lab was correlated with all the other frailty instruments (all P<0.001). The FI-Lab revealed an area under the receiver-operating characteristic curve (AUC) for 6-month and 1-year mortality of 0.765 (0.694–0.836) and 0.769 (0.706–0.833), respectively (all P<0.001). Each 0.01 increment in FI-Lab increased the risk (adjusted for age and sex) for 6-month and 1-year mortality by 7.2% and 7.1%, respectively (all adjusted P<0.001). When any of the other FIs (except the FI-combined) were also included in the models, each 0.01 increment in FI-Lab score was associated with an increase in the risk of 6-month and 1-year mortality by 4.1%–5.4% (all adjusted P<0.001).

Conclusion

The FI-Lab showed key characteristics of an FI. The FI-Lab can be applied as a single frailty measure or in combination with/in addition to other frailty instruments.

Comparing the predictive accuracy of frailty, comorbidity, and disability for mortality: a 1-year follow-up in patients hospitalized in geriatric wards

BACKGROUND

Studies evaluating and comparing the power of frailty, comorbidity, and disability instruments, together and in parallel, for predicting mortality are limited.

OBJECTIVE

This study aimed to evaluate and compare the measures of frailty, comorbidity, and disability in predicting 1-year mortality in geriatric inpatients.

DESIGN

Prospective cohort study.

PATIENTS AND SETTING

A total of 307 inpatients aged ≥65 years in geriatric wards of a general hospital participated in the study.

MEASUREMENTS

The patients were evaluated in relation to different frailty, comorbidity, and disability instruments during their hospital stays. These included three frailty (the seven-category Clinical Frailty Scale [CFS-7], a 41-item frailty index [FI], and the FRAIL scale), two comorbidity (the Cumulative Illness Rating Scale for Geriatrics [CIRS-G] and the comorbidity domain of the FI [Comorbidity-D-FI]), and two disability instruments (disability in basic activities of daily living [ADL-Katz] and the instrumental and basic activities of daily living domains of the FI [IADL/ADL-D-FI]). The patients were followed-up over 1 year.

RESULTS

Using FI, CIRS-G, Comorbidity-D-FI, and ADL-Katz, this study identified a patient group with a high (≥50%) 1-year mortality rate in all of the patients and the two patient subgroups (ie, patients aged 65-82 years and ≥83 years). The CFS-7, FI, FRAIL scale, CIRS-G, Comorbidity-D-FI, and IADL/ADL-D-FI (analyzed as full scales) revealed useful discriminative accuracy for 1-year mortality (ie, an area under the curve >0.7) in all the patients and the two patient subgroups (all P<0.001). Thereby, CFS-7 (in all patients and the two patient subgroups) and FI (in the subgroup of patients aged ≥83 years) showed greater discriminative accuracy for 1-year mortality compared to other instruments (all P<0.05).

CONCLUSION

All the different instruments emerged as suitable tools for risk stratification in geriatric inpatients. Among them, CFS-7, and in those patients aged ≥83 years, also the FI, might most accurately predict 1-year mortality in the aforementioned group of individuals.

Efficacy of L-carnitine supplementation on frailty status and its biomarkers, nutritional status, and physical and cognitive function among prefrail older adults: a double-blind, randomized, placebo-controlled clinical trial

Background

Frailty is a biological syndrome of decreased reserve and resistance to stressors due to decline in multiple physiological systems. Amino acid deficiency, including L-carnitine, has been proposed to be associated with its pathophysiology. Nevertheless, the efficacy of L-carnitine supplementation on frailty status has not been documented. Thus, this study aimed to determine the effect of 10-week L-carnitine supplement (1.5 g/day) on frailty status and its biomarkers and also physical function, cognition, and nutritional status among prefrail older adults in Klang Valley, Malaysia.

Methodology

This study is a randomized, double-blind, placebo-controlled clinical trial conducted among 50 prefrail subjects randomized into two groups (26 in L-carnitine group and 24 in placebo group). Outcome measures include frailty status using Fried criteria and Frailty Index accumulation of deficit, selected frailty biomarkers (interleukin-6, tumor necrosis factor-alpha, and insulin-like growth factor-1), physical function, cognitive function, nutritional status and biochemical profile.

Results

The results indicated that the mean scores of Frailty Index score and hand grip test were significantly improved in subjects supplemented with L-carnitine (P<0.05 for both parameters) as compared to no change in the placebo group. Based on Fried criteria, four subjects (three from the L-carnitine group and one from the control group) transited from prefrail status to robust after the intervention.

Conclusion

L-carnitine supplementation has a favorable effect on the functional status and fatigue in prefrail older adults.

Geriatric falls in the context of a hospital fall prevention program: delirium, low body mass index, and other risk factors

BACKGROUND

Inpatient geriatric falls are a frequent complication of hospital care that results in significant morbidity and mortality.

OBJECTIVE

Evaluate factors associated with falls in geriatric inpatients after implementation of the fall prevention program.

METHODS

Prospective observational study comprised of 788 consecutive patients aged 79.5±7.6 years ( [Formula: see text] ± standard deviation) (66% women and 34% men) admitted to the subacute geriatric ward. Comprehensive geriatric assessment (including Mini-Mental State Examination, Barthel Index of Activities of Daily Living, and modified Get-up and Go Test) was performed. Confusion Assessment Method was used for diagnosis of delirium. Patients were categorized into low, moderate, or high fall risk groups after clinical and functional assessment.

RESULTS

About 15.9%, 21.1%, and 63.1% of participants were classified into low, moderate, and high fall risk groups, respectively. Twenty-seven falls were recorded in 26 patients. Increased fall probability was associated with age ≥76 years (P<0.001), body mass index (BMI) <23.5 (P=0.007), Mini-Mental State Examination <20 (P=0.004), Barthel Index <65 (P=0.002), hemoglobin <7.69 mmol/L (P=0.017), serum protein <70 g/L (P=0.008), albumin <32 g/L (P=0.001), and calcium level <2.27 mmol/L. Four independent factors associated with fall risk were included in the multivariate logistic regression model: delirium (odds ratio [OR] =7.33; 95% confidence interval [95% CI] =2.76-19.49; P<0.001), history of falls (OR =2.55; 95% CI =1.05-6.19; P=0.039), age (OR =1.14; 95% CI =1.05-1.23; P=0.001), and BMI (OR =0.91; 95% CI =0.83-0.99; P=0.034).

CONCLUSION

Delirium, history of falls, and advanced age seem to be the primary risk factors for geriatric falls in the context of a hospital fall prevention program. Higher BMI appears to be associated with protection against inpatient geriatric falls.